COMPLIANCE INFO_1985-2006 - Laserfiche WebLink

Home Browse Search

FROM :B.Z.SERUICESTATION MAIN NCE FAX NO. :916 371 2540 AlkTan. 28 2005 09:26AM Pe MONITORING SYSTEM CERTIEFICATION For Use By All Jurisdictions Within the State of California Authority Cited.-Chapter 61,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form.must be used to document testing and servicing of monitoring,equipment. "rt mn for each mririiWdag ayg=control gaanel by the technician who performs the work. A copy of this form must be provided to the tank systern.owner/operator. The owner//operator must submit a copy of this fban to the local agency regulating UST systems withiti 30 days of test date. A. General Inflormad Facility Name: AA M V A+C-04- bldg,No.-_ Site Address: -191c�1 9- LnL-4 Ilk City:jg"'r Zip: Facility Contact Person:—im Contact Photte No.: MWWModel of Monitoring System: °IDate of Testing/Servicing: —t -/22/Al— B. inventory of Equipment Tested/Certified !��eto W"teWeemsffle e An! servkeda Model; 11 In-Tank Gauging Probe. Model- Space or Vault Sensor. Model: 13 Annular Model: ® Piping sump I TKonch Semor(s). Model: Mc Senor.r( e Tank ID: To g Prob A,A ..W S�or V..1 01 P Pin S. p n (3 �lj S4 SenSWS). el. Mod . 0 Fill Sump Sonsor( Modet 0 Mechanical Line Leak Detector. Model: 0 Mechanical Lino Leak Detector. Model- Q Electronic Line Leak Detector. Model: Q Electronic Line Leak I)axtor. Model., =Tank Overfill/Wigh-Level.Sensor, Model: Q Tank Overfill I Ifth-l-evel Sensor, Mo&l: 13 erespecifyLeguipment ryl)e and model in$ection.E on Page 2). Q Othaar s ut,type and model in Section F-on pit c 2), Tank ID: Tank ID: D 1-n-Tank(huging Probe. Model. 0 In-T40 Gauging Probe, Model- 0 Annular Spa=or Vault Sensor. Model" 0 Annular Space or Vault Sensor. Model: Q'Piping Sump/Trench Sensor(s). Model: U Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Cl Pill Sump Seusm(s), Model, Cl Mephanical Une Leak peteetor. model-. 0 Mechanical.Une izt&Detector. model: U Etectronic Line Leak Detector, Model; 13 Fiectronic Line Leak Detector, Model: Ll Tank Ow ll I High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor, M(Xlcl. type and model in Section E on Page 13 Others =and model in Section E oa LaE Q. Diqxmw IM Ili reser Ll Dispenser Containment Sensor(s). Model: (3 Dispenser ConWn=nt Sensor(&). model; Ll Show Valve(s), U Shear Valvo(s), -9 Dispenser Con taintowl-.Pio at(s)and ch!!aW. E3 Dismser CoutainmontnmUz and Chains)' Dispenser M. Dispenser W: 0 Dispenser Containment Sensor(g), Model: El Dispenses Containment Sensor(s). Model: 0 Shear V41*s). 0 Shear Valve(s), LA DiSREM C(Mwm=t Float(s)am,twain(91 U RLSEenser Containment Float(s)mid Chain(q)- Dispenser IID- Dispenser ID: Q Dispenser Contlinment Semor(s). Model: U DgRpensQr Containment Sensor(q). Model., Q Shear Valve(s). Q Shear Valve(s). LIUDis ser ConWn=nt Fjo&t j�� tainment 7�C7 -=�L U Dispenser Con Float(s)and Chain nf2l.— *If the facility contains rem or dispensers,COPY this form, Include infra nnation for every tank and dispenser at the facility. C. Ce OIC -I Certify Mat the equipment identified in"document was Inspedeft guldellue&.Attacbed to this Ce ti is erviced in ocordance with fliel-manufachirm, Information (". mauffiebirars, chadwsts) a to verify Mat Ugs Mrmation is cOrred&11d 2 of Plan showing the layout of awnhoring equipment.,For any rip t capable generating such reports,I have also attached a copy of the cJheck add t ystem set-up laM histo report TwInilcin Name(print): Signature, Certification No.: License.No.: Testing Company Name: Phone No.: Site Address: Date of Testing/Set-vicing: Page 1 of 3 03/01 M(Witaring System Certiffmation