COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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MONITORING SYSTEM C E TTS'T I lid I,ve Bay . (/l ,Jurisdictions 11'ithin: lh ,State gf'Cawi, s Aulhorily C.'ited: Chapter 6.7, He, th al&Sgfely Code; Chapter 16, Division 3, Title 23, California Code of Regulation,v This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The-owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days oft . date. A. General Information — Facility Name: 16WIN ,QtGC.��IA/10 Bldg. No.: Site Address: /Z? City: ,�/ Zip: Facility Contact Person: E Contact Phone No.: (0) 368-0603 Make /Model of Monitoring. System:14�� — ®EL0ELS000 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the annranriate hoses to indicate snecific enninment insnech Tank ID: NOWT4 ®tEgeA_- Tank ID: Lilt In -Tank Gauging Probe. Model: r4 Va . ❑ ht -Tank Gauging Probe. Model: Dl Annular Space or Vault Sensor. Model: Z L5 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: U 1.13 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: CQ Mechanical Line Leak Detector. Model: FX- 1 V ❑ 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 ecify a ui ment type and model in Section E on Pa e 2). ❑ Other (specify e ui ment ty a and model ' i Section E on Tank ID: ® In -Tank Gauging Probe. Model: MI }Gt . ❑ Annular Space or Vault Sensor. Model: IN Piping Sump / Trench Sensor(s). Model: It 1.5 ❑ Fill Sump Sensor(s). Model: Pill Mechanical Line Leak Detector. Model: rX -I V 17 ❑ Electronic Line Leak Detector. Model: ❑ Tank- Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Page 2). Dispenser ID: tJD1LT41 *b Ie6F_L_l� ❑ Dispenser Containment Sensor(s). Model: * Shear Valve(s). ® Dis enser Containment Float(s) and Chain(s). Dispenser ID: KSGC. MAIld ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: CAT*l 15 1 JE 77C ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). . ®Dispenser Contaimnent Float(s) and Chain(s). 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 ment type and model i Section E on Dispenser ID: ❑ Dispenser Containment Sensor(s). Model. ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). t Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains *If die facility contains more tanks oc dispensers, copy this form. Include information for ever; 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 attached a copy of the report; (check a// that applv): ❑ System set-up ® Alarm history report Technician Name (print): Z�1�,j, Al;,,,Q Signature: �- Certification No.: //;?3 License. No.: �" Testing Company Name: _ Phone No.: Site Address: Date of Testing/Servicing: 11 /2.1 /O$ Page 1 of 3 Monitoring System Certification A Results of Testing/Servicing 03/01 � �J