COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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MONrAMRING SYSTEM CERTMCAOON For M By AU fwisdirxions Wahin the State of CW&nzia Authority Coed C*Vmr&Z Health and Safety Code C hgpterl6.Dhision3.Taut 23.CaWbmia Cods ofReStdadons W.. This form must be used to document Nesting and servicing of MOGRoriag equipment.,&Separate certification or EMM must be nnenarvd for each monitoring mnym control panel by the toduucian who performs the work. A copy of this form must be provided to the tank System ownedoperator.-The owmelopetator must submit a copy of this form to the local agency tcgulating UST systems within 30 days of tela date, FGeN Informatioc.� � U 2 Z.S.'-' - -- - - -FacilityZaf Bldg.No- Site Address: �S�®G Go v/J L v� qty; Facility Contact Paaon: 41/CK Contact Phone No--(,91v Make/Model of Monitoring System: 11-T4 b DAp N of T 9 J.2E/L,:�Z B. Inventory of Equipment Teste&Certified a-ckd-apmmide %dicateaeffic TM&M. e TaakM. zz l�In-Tank CM&& ModeL-1/ R_- Model• (� SMworVaaltS== Model: - 1 0 AnnalarSpeceorWaitSemsor: Model- D NingSUMP ITrench Seasa(s). VVingSMP/TrM&Setsoc(s). Model:-❑I rW SUW Seasat(sj. Modd:� _ o FsIlSt®P sj. Moder: g. haniaiLimLeakDacaoc Model:- 'kZ" t�l`�o Q Mocintnical LioeLeak Drxocta Mold: � Cl Etect<oaicL=LtakDaezWc Model: ®EiactroWL=eLe*DdacWc. Model: TankOriaSl1liig9,c%vlSc=m Mod&O r /5'a ,LL_ A T=kOteer6ll/ Sw=.Model: /S 0 WX ❑Other( and model in Sexxioa E on 2 ®Odrer( mad model in Soetion E ort 2. Tank JD: Tar&M. ❑In-Teak Gauging Probe. Model- ❑la-TsakGaagM Robe. Mod&- ❑AnnuiarSpaceorVauitSensor. Model• ❑AmalarSpaceorVanitSensoc Mod& ❑Piping Sump/Ttench Sensot(s). Mode-- ❑Piping sump/Tiwch Sensor(s). Model: ❑ Fill Sump Sensor(s). • Model: ❑Fill Sump Sarsa(s). Model: ❑ Mechanical Linc Lcak Detector. Modcl: 0 Mochanical Me Leak Detector. Model: ❑E w onk Line Leak Detector. Mod L ❑ E cctro c Line Leak Dctoaor. Model: ❑Tank Ovafrll/High-Lewl Suuor. Model: ❑Tank Omfill/ Senor. Mod&: 11 Other(s to t model in Section Eat Page 2). ClOther( t and in E on Page 2). Dispenser M: 1-- Dispenser M. ❑Disperser Containment Sew r(s). Model: ❑DispenserContaiamart Sedsor(s). Model: "- Shear Val*s). QS-Shear Valvr(s). a D" Containment Float(s)and Chains)- 1 Di Cott ' Floats)and Chairt(s). DispenserED. +DispenserID: ❑ Disperser Contaimnent Seasor(s). Model- ❑DisparserContai t Sensor(s). Model: �a Shear Valve(s). ! Shear valve(s). (3 D" Containment Float(s)and Ch *). Ja DispeascrContainment Fioat(s and Chain(s). Dispenser iD: Dispenser ID: ❑Disperser Containment Sesor(s). Model: ❑DispenserContainment Satsor(s). Model: ❑Shear valve(s). ❑Shear Valve(s). ODispenser Containment Flodt(s)and Chain(s)- 1 ❑ Containment Floats and Chain(s). Off the facility contains more tanks or dispensers.copy this form. Include information for emy tank and dispenser at the facility. Q Certification-I certify that the equipment identified in this document was inspected/serviced In accordance with the manufacturers' guidelines. Attached to this Certification is information(e g.manufacturers'cheddists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. Forany ' ment capable of g eating such worts,I have also attached a copy of the (check all that app/y): %-systern set-up or port Technician Name(print):�• t' ; f- ---.h Signature: - Certification No.: a- > } cF License.No.: (. Testing Company I\amc:T't_L sas�,Q_ ,R_ y�r-enure�.-� Phone Site Address:25 2 t 916bir Date of Testing/Servicing: 1':q--c t 4if3 uZnt! \tuttitu-in_� a.•ut Ccrtitirttiern