COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

Home Browse Search

-r MON*ORING SYSTEM CERTIFOATION G�IV / For Us, B) '411J111_iS(1iC1i017S 1471hin the Slide of C'crlifbr-niu tl a/horih% C'i1ed: C11C7�7(L'/' 6. %, l(ect/Ih aad SufeltC ' 'oc1e; C'hapler 16, Division 3, 7ille 23, Culifbrnia Code o &pawiolls v This form trust be used to document testing and servicing of monitoring equipment. A separate certift r re of be prepared for each monitoring system control panel by the technician who performs the work. A copy of this vided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regu within 30 days of test date. A. General Information Facility Narne: Site Address: / %/_5 f®Ztt6kI Bldg. No.: City: _ Labr zip: �?.� Gr� Facility Contact Person: lit A f Contact Phone No.: ( GU`/+ Make/Model of Monitoring System: t1 eb% (- 015 L Date of Testing/Servicing: /1 / _T /6 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tanis ID: Ty fk k L l Tank ID: .& In -Tank Gauging Probe. Model: MJAL.j ❑ In -Tank Gauging Probe. Model: Ok Annular Space or Vault Sensor. Model: Is (pL_v t ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: LS ` 5<� ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model:��-) �fj� ❑ 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 (specify equipment type and model in Section E on Pa a 2). ❑ Other (specify equipment t e and model in Sectio4 E on Pae 2). Tank ID: V 11'eilr f- L - Tank ID: IR In -Tank Gauging Probe. Model: ljL7 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: [ L ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: ❑ 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 ecif a ui ment type and model in Section Eon Pa a 2). ❑ Other (s eci a ui ment type and model in Section E on Pa 2). Dispenser ID: f Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: C3 Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: PUliear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 0 41U.4 A 1 Dispenser ID: Dispenser Containment Sensor(s). Model: EI 'Dispenser Containment Sensor(s). Model: _ Shear Valve(s). ❑ Shear Valve(s). 2LPispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 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 Phan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that app/j,): US.yst farm history report Technician Name (print): --74NR /'—,,2,,n Signature: 33x2 u r Certification No.: %0�L 5 License. No.: � O ,Ila 1.A, Testing Company Name:I DA- ~' esr Phone No.::J'<w _ D /� Site Address: I "//- 5 _ _ A&I W 0f Date of Testi ng/Servicing: T /C Page I of 3 Monitoring System Certification D. Results of Testing/Servicing 03101