COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

Home Browse Search

MONIA%NG 'SYSTEM CERT I O-_ ION For Use By All Jurisdictions Within the State of California Authoil t ry Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: PACIFIC BELL GEO PAR# UE-020 CLLC Code: LODICA01 Site Address: 124 W.ELM STREET City: LORI Zip: Facility Contact Person: KEN MCDONALD Contact Phone No.: 209-473-5430 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Service: 8/16/02 B. Inventory of Equipment Tested/Certified Check the aggropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 795 Tank ID: ®In-Tank Gauging Probe: Model: 847390-107 ❑In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: 794390-352 ❑Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794390-352 ❑Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ®Tank Overfill/Mgh-level Sensor: Model: 790091-001 ❑Tank Overfill/High-level Sensor: Model: ❑Other, S eci ui . e and model in Section E on Pa e 2 ❑Other,S eci ui a and model in Section E on Page 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: []Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: []Piping Sump/Trench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: []Tank OverfilUHigh-level Sensor: Model: ❑Tank OverfillMgh-level Sensor: Model: ❑Other, S eci ui . e and model in Section E on Pa e 2 ❑Other, S eci ui a and model in Section Eon PMe2 2 Dispenser ID: Dispenser ID: []Dispenser Containment Sensor: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dig enser Containment Float(O and Chain(s ❑Dig enser Containment Float(s)and Chains Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chains FlDisnenser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis eraser Containment 1712a,tN and Chain(s) ❑Dis enser Containment Float(s and Chain(s) *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. 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'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ® System set-up ® rm h' tory resort Technician Name(Print): BRANDON HAM Signature: Certification No.: 3435 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 03/01 Page 1 of 3