COMPLIANCE INFO_2005-2008 - Laserfiche WebLink

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_ MONSORING SYSTEM Sn +M CE - TJON I,-or Use[3t' I//Jrnriscliclions Within the ,Slate ofC'alrfornia .<lrrthority C ileal Cholver 6.7, llecr/I/r am%Sufchv C'ucle; C'hupter-16, Division 3, Tille 23. 0dli,rniu C'orle oflZe��trlutiun,r This form must be used to document testing and servicingg of monitoring b b equipment. A sepaaate, e�i�C+ atld'i7 �r tenoat nTust be prepared for each monitoring system control panel by the technician who performs the work. A copyl�hMis fdrnnMust be l.rotvkiecl to the tank system owner/operator. The owner/operator must submit a cow of this form to the local agency regulating UST systems within 30 clays of test elate. I,z4 sj t A. General Information Facility Name: ._ d r lPI �;( lits Tho k"' Site Address: ,55 H ) yl City: 44 zap• Facility Contact Person: �- s lea Contact Phone No.: (_) Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicate specific a ui ment inspected/serviced: Tank ID: .ate- Tank ID: lel In-Tank Gauging Probe. Model: 70-4 (41 OI.In-Tank Gauging Probe. Model: 9-Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 3 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 Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pa=e 2). C) Other(specify eui ment type 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: 0 ❑ Annular Space or Vault Sensor. Model: 19-Piping Sump/Trench Sensor(s). Model: i'`°> ❑ 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 Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif equipment ty a and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 7k ' C Dispenser ID: U'Dispenser Containment Sensor(s). Model: aDispenser Containment Sensor(s). Model:_ d ,W Shear Valve(s). 3,"Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: - Dispenser ID: - El-Dispenser Containment Sensor(s). Model: ` Dispenser Containment Sensor(s). 1Model• Ef Shear Valve(s). W Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: -- ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Contain-nent Floats)and Chain(s). ❑ Dispenser 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 attach d a copy of the report;(check a//that apply): ❑Sy em s up ❑aAlarm history report Technician Name(print): Signature: Certification No:: License.No.: 90 ',// Testing Company Name: c�rD.A Ste(' Phone No.:( !'q ) �V4—0 0,2, Site Address: Date of Testing/Servicing: - Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing