COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

Home Browse Search

MON Fr , /se By 1/l.%MIS&Cl011S ff "iihin the .Slulc nf'C'illi r;. MIA,Wliurily Ciled: Clxrplcr G.7, f/cull{ ancl Sufcl4 t �r7c'�C �tq�t�i IG /�usjon 3, 7ille 23, C'nlifnr17ia Code �f Re;�ulaliun.r This form must be used to document testing and servicing of nionitoriTro'�iiipment. A separate certification or report must be prepared for each monitoring system control panel by the who )erforms the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator mtisfabi"ipof this form to the local agency regulatii u7 UST systems within 30 days of test date. A. General Information 1 L:. ( Facility Name: �j�JC�i� {�O �-rC O L� Bid-. No.: g Site Address: te( City: lam Zi Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: �-pl t_(�� le -C h Ej-A( Date of Testing/Servicing: -/ ( p/ o8 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enuinnaent inspected/serviced: Tank ID: Tank ID: 9/ A In -Tank Gauging Probe. Model: G7 Z ¢I In -Tank Gauging Probe. Model: Ml A Z A Annular Space or Vault Sensor. Model: �!� 14 Annular Space or Vault Sensor. Model: zo ® Piping Sump / Trench Sensor(s). Model: Zoe _ ! Piping Sump / Trench Sensor(s). Model: ZO$_ ❑ Fill Sump SenS01-(S)• Model: ❑ Fill Sump Sensor(s). Model: A] Mechanical Line Leak Detector. Model:9;�GDZbb® 2r -Mechanical Line Leak Detector. Model: aD2oo® ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill /High -Level Sensor. Model: Ll Tank Overfill / High -Level Sensor. Model ❑ Other (s ecify equipment type and model in Section E on Page 2). ❑ Other (specify e ui . merit t ie and model in Section E on Page 2). Tank ID: Tank ID: /E�jdL ❑ In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: �+ 61 Z ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump /Trench Sensor(s). Model: IQ Piping Sump / Trench Sensor(s). Model:$ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model Wk Mechanical Line Leak Detector. Model: I -A Z000 ❑ 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 Page 2). ❑ Other (s ecify a ui anent type and model in Section E on Pa a 2). Dispenser ID: i '� �- Dispenser ID: (o 19 Shear Valve(s). a Shear Valve(s). Dis penser Containment Float(s) and Chain(s). AI Dispenser Containment Float(s) and Chain(s). Dispenser ID: $ v `� Dispenser ID: -!'tea $ W9 Q;&FwR9@r R Shear Valve(s).� 25 Shear Valve(s). Dis enser Containment Float(s) and Chain(s). A=Dispenser Contaimnent Float(s) and Chain(s). Dispenser ID: Dispenser ID: 1,j$' ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 013is enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *It the facility contains more tanks ordispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi ment capable of generating such reports, I have also attached a copy of the report; (check a// that applp): 0 System set- history report Technician Name (print):WR ZV;,zIM4I Signature: Certification No.: 893 License. No.: ,( w 52 .3'3x, 7 0 7 - Testing Company Name: _csr Phone No.:(Q6 9 )'74-1 — 0ZIA Site Address: Id MEt2 1 Date of Testing/Servicing:?//0 /0$ Page I of 3 Monitoring System Certification A Results of Testing/Servicing 5 03/01