COMPLIANCE INFO_1998-2007 - Laserfiche WebLink

Home Browse Search

Jul 31 03 11:02a Fr zen Hill 559 881467 p.4 NIO ITORING SYSTEINT CERTIFICATION Fa L'se BY ,411 Juristlicrions Within rile State of Cali o,,tin .4tithorirr Cited. Chapter 6.7, Heahh r;rrd Srtfen' Code; Chapter 16. Division 3, Title '3, California. COd o Regulations This for rt must be L: c 3 to dOcll ^ tC tes:ln, a:ld 'c :_-vicing ofsc': cCr '- r } t ' '�rt :or each nonitorin� stst:rt cont-ot oar.e, b; tl:: :r c ,.� r t.-� t .a,ion er reg r to -r ort mt.St be re ared c p_r.arnts �� xk. A caCY of this form must be s s:e::: owner.'oger�cor. The o�.�•tzetioperz;or t::st submit a cop; of t'r;; for•;t ,, t..c Local anenc ,: Provided to the tank daps of test date. "' , y red tIa,ing LST systet:ts within 30 A. General information r editI lame: _ N0 Ntn met rkp7- C. 7L IE u vim' Site address: `2 5Q / lc - )3Idg. No.: uC/�SeAj City: cu.r�• =aciLryContact Person: S«"r•'T �Fc5 i/t; Zi. 75311>z3 vlakeodel of iVfonitoring System: �^ to(r Contact Phone No.: N4 z 9 s ?? -1 ��„ • / Date of TestingiServicing: L/z Z /dc•? 3. Inventory of Equipment Tested/Certified :heck thea ro riots boxes to indicates ed rs a ut ment ins ected/serviced: _alk ID: ft!Aj>,-D Tank 1D: ��tKt tJ�''`t 'jt',In-Tank Gauging Probe. Model: $ 73 -gyp a In -Tank Gauging Probe. �'�nnular Space or Vault Sensor. Model• g Model: 1i Piping Sump/ Trench Sensor(s). Model: y2G IR Annular Space or Vault Sensor. Model: )/dill Sump Sensor(s). Model: -� `3�Ct -Zc'S ®Piping Sump /Trench Sensor(s). Model:g- e Mechanical Line Leak Detector. Model: 7 GO Fill Sump Scnsor(s). Modcl: 2�U ® Mechanical Line Leak Detector. Model: 1 1r�1 ' Ove Line Leak Detector. Model: O Electronic Line Leak Detector. Model: �Yfank Overfill /High -Leve! Sensor. Model; ��u_ � ,y�yr�D I Other s ecif a ui ment type and model in 5ectton E on Pa e 2 0 Tank Overfill / High -Level Sensor. Model: , Qu„¢y n Dn7�Ti/� an ID: S ) 0 Other (s eci. equipment t e and model in Section E on Pa a 2). e On-TanTank ID:k Gauging Probe. Model: �"l0� ❑ In -Tank Gauging Probe. 1f` lar Space or Vault Sensor, Model: Model: ❑ Annular Space or Vault Sensor. Model: tping Sump/ Trench Sensor(s). Model: � � r 7,�y p Piping Sump / Trench Sensor(s). Fi�Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model: cchanical Line Leak Detector. Model: Model: El ctronic Line Leak Detector- Model•? LSV — ❑ Mechanical Linc Leak Detector. Model: wank Overfill / High -Level Sensor. Model: ® Electronic Line Leak Detector. Model: Other (s ecif e ui mento and model in Section E on Pa e 0 Tank Overfill / 1•tigh-Level Sensor. Model: D Other (specify a ui mcnt r— and model in Section E on Pa a 2). rpenser ID: /42— . Dispenser containment Sensor(s). Model: Dispenser ID; Shear Valve(s). O Disperser( untainmentSensor(s). Jtitodel: .Dispenser Containment Float{s) and Chain(s). A Shear Valve(s). penscr ID: ® Dispenser Containment Ftoat(s) and Chain(s). Dispenser Containment Sensor(s). Model: Dispenser ID: Shear Valve(s). 0 Dispenser Containment Sensor(s). Model: Jis enser Containment Floats) and Chain s). ® Shear Valve(s). •>enser ID: D Dis enser Containment Float(s) and Chain(s), Dispenser Containment Sensor(s). Model: Dispenser ID: ;hear Valve(s). O Dispenser Containment Sensor(s). Modci: ® Shear Valve(s). is enser Containment Floats) and Chain(s). heDispenser Containment Float(s) and Chain(s). facility contains more tanks or dispensers, copy this form. Include information forevery tank and dispenser at the facility. 'C'ertification - I certify that the equipment identified in this document was inspected/serviced in accordance Nvith the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) neeessar)• to verify that this information is correct and a Plot Plan showing the tavout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): PP})Z1,Systcm set-up 'A arm history report hnician Name (print): r Signature: :ification No.: e� � 2 9S /& I y License. No.: _ 'ng Company Name: , �� ,LZ 2Phone No.: 5-59 A address: e o i 5 f, M1 �4 rr 2 7 Date of Testing/Servicin /22 � 1'� / .� ?coring System Certification Page I of 3 03/0I