COMPLIANCE INFO_1991-2008 - Laserfiche WebLink

Home Browse Search

MOM ORING SYSTEM CERTI&ATION For Use By All Juris&clions Within the State of California Authority Cited,- Chapter 6.7, Health- and SVky, Code; Chapur 76, Division 3, Title 23, California Code of Regulations ----- ----- system owner/operator. The owner/operator must submit a copy of this form to the local agenrtp 7ist within 30 days of test date. A. General Information Facility Name: Normts 76 JANA 3 �004 d7g. o.: Site Address: 633 East Victor Road City: I -ad E1,VIRONMEM-0. EALTH Facility Contact Person: ]Rnb Contact Phone No.: LE R M I T/P E RV I GES— *-Make/Model of Monitoring System: Veeder goot TLS 250 Date of Testing/Servicing: 12 / a_/_03_ B. Inventory of Equipment Tested/Certified Check the appropri 1nocate iafte boxes to' mecmc equipment - .-.-Tl Super I Tank ED- T2 Plug FTank ln4-aruc Gauging F-obe. Model: 784290-307 in -Tank Gaugging Probe. Model: 7B42aO-307' Annular Space or Vault Sensor. '10C MJP W Annular Spam or Vault Sensor. Model: Rq-n-w Piping Sump / Trench Sensor(s). 94 0 Model- 30 jP Piping Sump f Trench Sensor(s). Model: SRS794300-205 U Fill Sump Sensor(s) Model: U Fill Sump Sensor(s). Model: Mechanical Line Leak Detector- 1 Model: R. I FYI Y 9 Mechanical Line Leak Detector. Model. gj FXjV Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: M 61 SQp Tank Overfill 1 Higb-Level Sensor. Model. MX7 A Otber ilr)r u:1 ment and model in Section E on Pa U Other (specify uipment wpe and model in SZZdon r in Na 2) TankID:.--- T3 Regular Tank ED; In -Tank Gauging Probe. Model: 784290-307 13 In -Tank Gauging Probe, Model: !2 Annular Space or Vault Sensor. Model- 1 13 Annular Space or Vault Sensor, Modeh IP& Q PP; ' Sump/ Trench Sensor(s). Model, U Piping Sump / Trench Sensor(s). Model-, 13 Fill Sump Sensor(s). Model; U Fill Surnp Sensor(s). Model - V Mechanical Line Leak Detector. Model* it EX1 V 0 Mechanical Line Leak Detector, Model: U Electronic Line Leak Detector, Model: 13 Electronic Line Leak Detector. Model: -erffl' I -Level Sensor. Q Tank Ov I i Higil Model: ()M &I c &)p Q Tank Overfill / High -Level Sensor. Model: 1 .'Od k 61 her model in Section E onPa 21 E3 Other( EqTpment pM and model m SectionE on Pageti a i Dispenser I U).-. & 2 DisPenser' ID- 3 & 4 - I y? Disperser Con Sersor(s). Model: audr-aau joa t3 Dispenser Containment Sensor(s). Model: Beaudreau 900 Shm- Valve(s). P Shear Valve(s)- Dispenser Containment Flo�*(�2 and I.------ Rj5)er-wr C�antain�t Flowit(s) and Chain(s). Dispenser IR 5 & 6 A-61spenser ID: 7 & 8 Dispenser Containment Sensor(s). Model: B024,d,eaj, 5clo Dispenser Containment Sensor(s). Model: Rea _gll 9()o )IV S1,ear Shear Valve(s). V- Disperser Contaimment Float(s) and Chain(s). �R Dispenser Containment Floal(s) and ain S). W I Dispenser ID: ispenser ID: TDOMDispenser Q Dispenser Containment Sensor(s). Model: Containment Sensor(s). Model: 0 Shea-Valve(s). U shearvalve(s). I r"IDispeaser Contairunent Float(s) and Chain(s). U Dispenser Containment Float(s) and Chw-W C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufactur guidelines. Attached to this Certification is information (eg. ws ufacturers' checklists) necessary to verify that this information co-rect and a Po lt Plan showing to he layut omon f itoring equipmesL For any equipment capable of generating suc repo rts, I have at ,11 istory attached a copy of the report; (check aa ll tht applyem -up rm h ). Q Systset(3 7 Technician Name (print): James P. Hesketh Signature: Certification No.: 9692/436 License. -IN, .: 817186 Testing Company.Name: Hesketh Construction Phone No.:( 209 754-4452 SiteAddress: P o BQ� 758, Mountain Rancb. CA 95946 DateoffestinglServicing: 12 /29 /03 1 Pap 103 03/0) Monitoring System Cerfifwation -