COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

Home Browse Search

MONIT(*NG SYSTEM CETIFI ION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, Title 23, California od�Vegulations This form must be used to document testing and servicing of monitoring equipment. A separate certificatioh� /e 4f'must be prepared for each monitoring system control panel by the technician who performs the work. A copy of thi orm must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local a cY UST systems within 30 days of test date. A. General Information Facility Name: PACIFIC BELL GEO PAR# UE-020 CLLC _ rolxcAoi Site Address: 124 W.ELM STREET City: LODI Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209-474-4514 Make/Model of Monitoring System: TLS-2501 Date of Testing/Service: 8/16/01 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific a ui ment ins eted/serviced: Tank ID: 795 . Tank ID: ®In-Tank Gauging Probe: Model: 784290-307 ❑ln-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: 794380-205 []Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794380-205 ❑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: OTank Overfill/lEgh-level Sensor: Model: 791191-001 ❑Tank OverfilUHigh-level Sensor: Model: ❑Other,S eci ui . e and model in Section E on Page 2 ❑Other,S eci ui . e and model in Section E on Pa e 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 Overfill4ligh-level Sensor: Model: []Tank OverfilUHigh-level Sensor: Model: ❑Other,§pecif X Squip. e and model in Section E on Page 2 ❑Other,Specify ui . and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). p Shear Valve(s). ❑Dis eraser Containment Float(O and Chains ❑Dis enser Containment Floats and Chains Dispenser ID: Dispenser ID: ®In-Tank Gauging Probe: Model: ElDispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s),and Chains []Dieraser Containment Floats)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): U System set-up 13 Alarm history report Technician Name(Print): DON THOMPSON Signature: L �, btr�� Certification No.: 545-92-3354 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTSEMS Phone No.: (714)560-8222 Page I of 3 03/01