COMPLIANCE INFO_2003-2005 - Laserfiche WebLink

Home Browse Search

' 01/30/2003 09:12 818 29TRIAI&E PAGE 01 MONITORING SY EM CERT CA TION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter t5.7,lVealth and Safety Code,Chapter JG,/Division 3.77rk 23,California Code of Rcgulationc This fora must be used to document testing and servicing of monitoring equipment.A-sevarate certification grin=must he prepared for each MOWWdBL13MLem con 1 anal by the technician who perfor mt the work. A copy of this foam must be provided to the tank system owner/operator. The owner/operator must submit a copy of thk form to the local agency regulating T.IST systems within 30 days of test date. A. General Information Facility Namc: ✓l S7a ,t�� Bldg.Nn..- Mir n.:Site address: JI 9 6 ov, k� A est City: & ""r4 C.1 Zip: 7 �.3 Facility Contact Person: Contact Phone No.:( - Makc/Model of Monitoring System: &-O 46� Oats of Testing/Servicing- R. Inventory of Equipment Tested/Certified Cheek the appropriate hazes to indicate alit ftspectedfservictA. Tank IA: T k 111: In-Tank Gau&g Probe- Model: <' ' -Tank Gauging Probe. Model: M — Annular Spaec or vault Sensor. Madel: tinutar$pace or Vault Sensor. Model: 10 Piping Sump/Trench Senvor(s), Model: Piping Sump/Trench Sensor($). Model: _2 U 13 Fill Sump Scnar+r(s). MOM: O Fill Sump Samods). Model. -W Mechanical Line Leak Detector, Model; p44edwical Line Leak Detector. Model: �X Cl Electronic Linc Leak Detector. Model: ®Elcodronic Line Leak Detector. Model: V Tank Overfill/Hi -Lxvel Sensor. Model: CTonk Overfill/ °�...�. CJ High . r. Modelf`? 2j,,/ Z/S' ❑Other u' nt t and model in Section E on Po 2). Others f tri t type and model in Section E on Page 2). Tank U): Tank ID: O In-TankGauging.Ptobe, Model: D In-Tank Gauging Probe. Model: ❑ Annular Space;or Vault Sensor. Muret: O Annular Space or Vault Scnsnr. Model: O Piping Stnnp/Trcnch Scnaor(s). Model: O Piping Sump/Trench Sensor($). M(xlct: ❑ fill Sump Sensor(s), Modal: ❑Fill Sump Sensor(s). Model: O Mechanical kine Leask Detector. Model: ❑Mechanical Linc l cok Detector, Model: ❑F(ceavnic Line Leak Detector. Model: O Elecirtmic Line Leak Detector. Modcl: O Tank Overfill/High-Levet Sensor. Model: O Tank Overfill l High-Level Sensor. Model: O Ocher a e ui ment t and m el in Section E tm P e 2). l7 Other S edf tri mcnt and model in$cction E on Pao 21 D ' ID: ID: L a—Containment Senacx(s). Mndcl:�� penser Confainment cneatc). Model:alve(S). C S&M-Valve(t). ❑ Dis nser Cuntainmctit Floats and i ❑ p' Containment Flocs and Chains. D'pposer ID; Dispearer ID: 0-15aq.xme'ContainmcntSencor{s). onto: ❑ Dispenser ContainmctttSensor(s). Model: D Shcar Valve(„). ❑ Shclw valvc(s). O Dispenser Containment Float(s)and Ch.nin s, ❑ Dispmscr Containment Float(A)and Chain(s). Dispenser ID; D'espeneer ID: O DispenserContainanentSensnr(s). Model: ❑ DispetiserContainmentsenmr(v). Model; ❑ Shcai valve($). Q Shear valve($). 0aspen.,tcr Containment Floc s and Chains. ❑ DiopcnAcr Containment Fluat a and Chmnfs `Tf the facility contains more tanks or dispensers,copy this form. Include Wbrmatirnt for every tonk and dispenser at the f itity, C. Ctr(ifk2ttOn-I tertlfv that the equipment identifier]in tills docutpent was inspected/$e- teed in acco a with the mant rs' gutdelinec. Attached to thiA Certification tc information (e-g. ufaeturers' tlreckl! ) atceeeArp verity that this ttrmr ir correct and A Plnt Pinn showing the layout of monitoring a uip nt. For any equi nt le, merntiog such T have Also attacher♦a ropy of the t -fch�that apply): ystem set-tip ,Alarm hd 'y repnrt Technician Nnmc(print)' l l n2�1=91,” S;Foaturo- -- Ccrtiiication No,; Tccting Company Nnmc: 525 is tI Phone No.: ® — • S;fc Address _ BURBAN& Dntc of Tccting/Scrvic,r:: /_fid/0 Page I of n3rnt h'fonitoring System Certification