|
04/27/2005 09:40 805-6580069 TANK TEAM INC
<br />PAGE 02
<br />®NITORING SYSTEM CERTIFICATION
<br />For U.re By All Jt(risdirtion.s Within the State of California
<br />Authority Cited; Chapter 6.7, Health and SafetY Code; Chapter 16, Division 3, Title 23, California Code of Re°gidalions
<br />This form must be used to document testing and servicing of monitoring equipment. A Separate certification or.tgp_on,.trtust be t)regdred
<br />for eacjtU.jtSL>>latc�rin�systettt control novel by the technician who performs the work, A copy of this form must be provided to the tank
<br />system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30
<br />days of test date.
<br />A. General Information
<br />Facility Name, C o % ®,^A, "q „,,,..Ar+w•+7 G7,r��rmk,� %� err.4a% „af-c9e %f-d'N, Bldg. No.; -
<br />Site Address: age� � 1 �, � as �r �� _ City: Zip: q4206
<br />Facility Contact Person: 5F6 ee. e 1 4o _ .t - Contact Phone No.: ( ) S 3 /
<br />Make/Model of Monitoring System:EW &jT6"-C K 4 Date of Testing/Servicing: IO,__0_LLa e,7®+7(
<br />B. inventory of Equipment Tested/Certified
<br />Check the appro rtate boxes to indicate ecific c ui ment Inv ected/serviced:
<br />Took ID;
<br />Tank ID:
<br />❑ In -Tank Gauging Probe.
<br />Model; _
<br />a ,-
<br />CP Tri -Tank Gauging Probe, Model:
<br />4 -Annular Space or Vault Sensor.
<br />Model:..,,„_
<br />❑ Annular Space or Vault Sensor.
<br />Model:
<br />18 Pining Sump / Trench Sensor(s).
<br />Model:
<br />❑ Piping Sump/ Trench Sensor(s).
<br />Model;
<br />❑ Fill Sump Sensor(s).
<br />Model;
<br />❑ Fill Sump Scnsor(s).
<br />Model:
<br />A Mechanical Line Leak Dc(cctor,
<br />Model: _
<br />Q Mechanical Linc Leak Detector,
<br />Model; -r-
<br />❑ F,lcctronic Linc Lcak Detector.
<br />Model:
<br />❑ Electronic Line Leak Detector,
<br />Model: ^_
<br />❑ Tank Overfill /Nigh -Level Sensor.
<br />Model
<br />❑ Tank Overfill / high -Level Sensor.
<br />Model:
<br />❑ Others eci a ui ment tXU and model in Section F on Pae 2).
<br />❑ Other �s2cc& c tui . mcnt type and model in Section V on Page 2).
<br />Tank ID:
<br />Tank ID:
<br />❑ In -Tank C*auging Probe.
<br />_-
<br />Model:
<br />_
<br />❑ In -Tank Gauging Probe, Model;
<br />❑ Annular Space or Vault Sensor.
<br />Model;
<br />O Annular Space or Vault Sensor,
<br />Model: „
<br />❑ Piping Sump / Trench Scnsor(s),
<br />Model:
<br />❑ Piping Sump / Trench Sensor(s).
<br />Model:..,.-
<br />❑ Fill Sump Sensor(s).
<br />Model: ,.„,.,,_.,-„
<br />❑ Fill Sump Sensor(s).
<br />Model;
<br />❑ Mechanical Line Le.tk Detector,
<br />Model;
<br />❑ Mechanical Line Leak Detector,
<br />Model:
<br />❑ Electronic Linc Leak Detector,
<br />Model:
<br />❑ Electronic Line Leak Detector,
<br />Model;
<br />❑ Tank Overfill / High -Level Sensor,
<br />Modcl;
<br />❑ Tank Overfill / High -Level Sensor,
<br />Model;
<br />❑ Other (s ecif equipment t and model in Section F. on Page 2).
<br />❑ OtheqWecify equipment and model in Section E on Pae 2).
<br />Dispemscr TD:
<br />Dispenser ID:
<br />Dispenser Containment Sensor(s).
<br />Model: _.__.
<br />C-1 Dispenser Containment Senmr(s).
<br />Model . ............. .............._ —
<br />❑ Shear Valve(s),
<br />❑ Shear Valve(s).
<br />❑ Dis nser Containment Floats and Chains .
<br />Q L)is cnser Containment Float(q) and Chain(s).
<br />Dispenser ID;
<br />-,.....,._.,..:.:.........,.,�,.--
<br />Dispenser ID:
<br />-.._.
<br />❑ Dispenser Containment Scnsor(s).
<br />Model; _
<br />❑ Dispenser Containment Sensor(s).
<br />Model:
<br />Q Shear Valve(s).
<br />Q Shear Valve(s).
<br />❑ Dispenser Containment Float(s) and Chain(s).
<br />❑ Dispenser Containment Floatsj and Chains .
<br />Di3penser ID:.....
<br />Dispenser TD:
<br />_
<br />Q Dispenser Containment Semor(s).
<br />Mixlcl: _
<br />U Dispenser Containment SenSQr(S).
<br />Model:
<br />❑ Shear Valvc(s),
<br />❑ Shear Valve(s).
<br />ElDispenser Containment Floats) and Chain(s),
<br />© bis cnscr Conr.ainmcnt Float(s) and Chain(s),
<br />*Tf the facility contains more tanks or dispensers, copy this form. include information for every tank and dispcnser at the facility.
<br />C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the mTnufacturers'
<br />guidelines. Attached to this Certification is information (e.g. manufactureb.”
<br />'ecldists) necessary to verify that this information is
<br />correct and a Plot Plan showing the layout of monitoring equipment. For an ca ble of generating such reports, I have also
<br />attached a copy or thet�e port (thee 11.it..)tat ply): ❑ System set-upa story report:
<br />Technician Name (print): UEO- r a t e.i Signatur
<br />Cerdrication No.:. L4 G_0 !te License. No.:
<br />Testing Company Name:(/./-. /� %_&ry A-- _V., d Phone No.:(e-, p4g-} 6-Fg- & 7�
<br />Site Address: ,r� �/`� � � fr- f , _ i}v � y tv* Date of Testing/Servicing:' ®_/.1Lj_0 Y
<br />Page i. of 3 R3/Rl
<br />Monitoring System Certification
<br />
|