COMPLIANCE INFO_2009-2013 - Laserfiche WebLink

Home Browse Search

C4 ,� MON I G SYSTEM CE TIS ' 'I IS For Use By .4!l.Iru iscliction,s 11 Whin the .State of C'ulifor nicr Ailthor•ity Citee Chapter 6. 7, Health curt! S'ufery C ocle; Chapter 16, Division 3, Title 33, Caliifiu-inti Cot% of Regulatiolzs, This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each m�m onitorinystecontrol panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/opei�ajor must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneralInformBtion Facility Name: CGi 1, 15 t? y-- ,F ni vle n Site Address: 7 7 -7 W P -�-, City: Facility Contact Person: 0 Contact Phone No.: Make/Model of Monitoring System: 6 /. B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicatespecific a ui ment inspected/service Tank ID: / C1 In -Tank Gauging Probe. Model: 0 nnular Space or Vault Sensor. Model: Ef Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pave 21. Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model: Model: Bldg. No.: _ Zip:'40 Date of Testing/Servicing: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify e ui 2111enLjoe and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment ty a and model in Section Eon Page 2). Dispenser ID: ❑ Dispenser Containment Sensot•(s). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s} ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Flosrt(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Floa(s) and Chain(s) • ❑ Dispenser Containment Floats) and Chain(s). *'Ifthe 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 withh 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 P so .)ttachQd a copy of the report; (check all that npplt) ElSyst ` s�ttq( ❑ Alfii:m history report Technician Name rint 22, �V,'mmn Si -nature: / a Certification No.: License. No.:, Testing Company Name: t�rili� p !E Phone No.:( 0q Site Address: Date of Testing/Servicing: Monitoring System Certification Page I of D. Results of Testing/Servicing 03/01