COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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' p G SYSTEM CERTMCATION For Use ByAff Jurisdictions Within the State ofCalifornia iluthorfty Cited• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tide 23, California Code ofRegulations This form must be used to document• testing and servicing of monitoring equipment If more than one monitori-pg systemcontrol panel is installed at the facility; a separate certification or retort must be pref�ared for each morirtoting system control Hanel 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 of test date. Instructions are printed on the back of this pager A. General Information Facility Name: ' • r/ I� O o j 3,_�BIdg, No- SitjnAddress: %/� / .P'% y��C- City: Zip: / Facility contact Pea a: r Contact Phone No.: N.L J. 5 `` v� - Make/Model of Monitoring System: _ _ _ C- tr • jof Tcsing/Scrvicing: [2--)L- = / 'I B. ' Invefntor3' of uii meat Tested/CertifiedJ, / _ ' � �P (heck the appropriate boxy to indicate specific equipment inspectedlsesviced: Talk 1D: • % " V.ia qT ak Gauging Prab& Mode:' � Tank ID: (d.Ie.-Task Probe. .. Model: / ' � , 1 Id Annular Space or Vault Season: Medd:. N t' A :.Annular Space or Vault Sensor. Model:.�- 2 lar ingSump/TrenchScu=(s). Mudd: APipingSump /TrcachSers*4 _ Model: •r; _za ❑ •Fill Sump Sarsor(4 - Mode: � �._- E3 Fdl'�p Scasor(s) Model: -- X . . I:me Leak pctect= Medd:: L' . �. � Mccimnical bine Leak Detector. Model: ;,} . ❑ IIccnvnicl,iaeLcakDdxtor. • . Mudd: ❑ ElcctrqnicUncLcakDdcctor.. Modd: . la Tank Overfill / M& -Level Sensor. Model: � Tank Ovafll /High -1 evd Sensor.- Mod& Dispenser Containmrnt Sensor(s).. Medd: ❑ .Dispenser Coatainn=t Scnsor(4 Model: Af Shcar Valvc(s). - fil Shear Valvc(s). - ❑ Disperser Containmcat Floats) and Chain(4 ❑ Disperser Containmart Floats) and chain(s) . ❑ Other (specify equipment type and model in Section E on Page 4 ' :. ❑ Other (specify equipment 4W and mode in ScctioriE.pa Page. 2). . Tank ID: %-- Tank ID: 1 In Tank Gauging Probe. Model: I (`1 /` ` ❑ In -Tank Gauging Probe �Modd: Annular Space or Vault Sensor. Model: t," i ❑ -Annular Space or. Vault Seasoc Model: ! Piping Sump /Trench Scnsor(s� Model: i / �1, `a 1 ❑ Piping Sump/ Trench Scasor(s). Model: b Fill Sump Sensor(s). Model: jH. Mechanical Line Leak Ddc=. Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. _ Model: ❑ Electronic I: nc Leak Detector. Model: ❑ Etoctroaic Line Leak Detector. Model: P. Tank Overfill / I•rrgh-Level Sarsoc. Model: ❑ TankOvafll / Wtigir-L<wd Sensor. Model: ❑ Dispeasa• Containmcnt Scasor(s). Mode: ❑ Disp4aser Containmcat Sansor(s) Model: 0 Shear Valve(s). 13 Shear Valve(s). ❑ Dispenser Containment Floats) and Cihain(4 ' ® Dispenser Containment Floats) and Cham(s} - - • : .:.. •: ❑ Other (specify type and modd in Section Eon Page 2):. ❑ Othr(shy equipment type and model in Section Eon Page 2}. . C. Certification —I certify -that the equipment identified in -this document was inspecterl/seMced.in accordance with the manufacturers' guidelines. Attached to•this•C.ertification is information (eg. manufacturers' checklists) necessary to verify that this information is correct and a.Site Plan showing the layout of monitoring equipment... or any.equipment- pable of genemfing such rcports, I have also attacked a copy of the (check alt that apply): System set-up rt; Alarm history repo rt - T "chap Name t): l > � i' t =r..�� ;�` ic. 2�io.:� �