COMPLIANCE INFO_2000-2009 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By All.lurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tate 23, California Code of c 11 orr re rtes This form num be used to document testing and servicing of monitoring equipment. A P *0 llir h nllttitarintr cv _ dxr l by the technician who performs the work. A copy of this form must be provided systems to the / tint. The / for submit a copy of this form to the local agency regulating UST within 30 days of test date. A. General information Station No.: Facility Name: A 5_. 71 Site --Lno �-c City: 'a 14 7 ce; Zip: Facility Contact Penson: _M f e`E'1/l//� Contact Phone No.: Ma del of Ma Date of Service: B. Inventory of Equipment Tested/Certified tiu a uiTlosen►iced: T k ID: ID. elf',fiTank Gan Model: �4 �- Tank Gauging Probe: Model: f: t S or Vault r: Model: ) Space or Vault Sensor Model: t3? S1.3��'YdS Sump/Trerieh (s): Model: g Sumpll'rench Sensor(s): ModelI S (s) Model: ) Cf � Sump Sensor(s): 't4 Mode 'cal Line or. Model: chanica!Line Leak Detector.ClE c Line D r Model: ctronic Line Leak DetectorCTrank Model: 1911-4evel Sensor: Model: OTank Overf ll/Eligh-level Sensor: : Q. 1 in on E on rye 2 S and model in on E on Pa 2 . Tank ID:VID, OIn-T : : 1: S or Vault Model: OA S or Vault Sensor l: , h , r(s), Model: c ®piping S Tench (s): l:OFill Sump,Sensor(s): Model:r(s): !: 6 'd ift C*echanical Line Leak betector. Model: L 0 2 t/'erD ❑Mechanical Line Leak Detector. Model: oBlectronic Line Leak Detector Model: ®Electronic Line Leak Detector Model: ®Tank Overfill/High-1 i r: Model: OTank OverfillMigh-leve!Sensor: Model: opwg !mode!ian Section E on Page 2 Other S tri , and model in Section E on Pa 2 Dispenser ID-. 40 Di ID: , Model: 0INspenser Contal t Sensors: Model: ®Dispenser Containment Sensar(s}: O S. V s). O Shear Valve(s). p C t Float s and Chains ODi neer Containment Float s and Chain s D' ID: �°' Dispenser ID- Dispenser ® Model: 2.. ODi r Containment Sensor(s): Madel: 2. O Sheet Valve(s). E) Spar Valve(s). Fl s Chains Con t Floa s and C s oDispenser Containment,Dispenser ID: jDispenser ID: O etit Sensors: Model: `L Z O13i Containment Sensor(s): Model: �— z O Shear Valve(s). O Shear Valves). Conti of Flows)and Chains ®Di ser Containment Floats and Chain s *lf the facility contains snore tanks or dispensers,copy this form. Include information for every tank and dispenser at this facility. C. Certification • l certify that the equipment identified in this document was inspected/serviced in accordance with the matraf e"ren, gut- mints. 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 Gave fit"attached aco the�,�w.�rt;( an that t3'): 13 System set-up ® hi r roprt Technician N (print): ! + h Signature: Service Technician No.: S' d ' cation No.: Irl�t/ License No.: Testing C Name: ChA*r+pron Precision Testing,Inc Phone No.: (651)363»7400 03101 Pare 1 of 3