COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

Home Browse Search

MONITO G SYSTEM CERTIFICAOON For Use By All Jurisdictions Within the State of California ® V V Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code This form must be used to document testing and servicing of monitoring equipment. A stearate certification or reportttltli b for each monitoring system control panel by the technician who performs the work, A copy of this form must be provided to thVt system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating USWR@NMWT4&LTH days of test date. A. General Information Facility Name: ( c tr s Site Address: '9 Facility Contact Person: \ c w�. Make/Model of Monitoring System: Gdp tl B. Inventory of Equipment Tested/Certified Tank ID: JTIn-Tank Gauging Probe. PbRode1. ' '_ ^liJ Annular Space or Vault Sensor. Model: fes' Piping Sump /Trench Sensor(s). Model: t ' ❑ Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: Model: g Tank Overfill / High -Level Sensor. — ❑ Other sEecify a ui menta and model in Section E on Page 2). Tank ID: D,1_Ikngj In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: C. Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Detector. Model: Model: Mechanical Line Leak - Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model:('`e C3 Other (specify equipments type and model in Section E on Page 2)._ Dispenser ID: g) 2— r IA Dispenser Containment Sensor(s). Model: sal t�ScJ'�t?�S Pf Shear Valve(s). O Dispenser Containment Floats) and Chain(s). Dispenser ID: `1 '®` I' g1 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chair Dispenser ID: % &Dispenser Containment Sensor(s). Model: MShear Valve(s). C ntainment Float(s) and Chain(s' Bldg. No.: _City: zip: C) 0 Contact Phone No.: ( ) (� o S Date of Testing/Servicing: Tank ID: _ _11 59 In -Tank Gauging Probe. Model: _moi%RC1 t o'7 f11 Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: % =' ❑ Fill Sump Sensor(s). Model: Model: C'Oi e !`► JIS-Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: % Tank Overfill / High -Level Sensor. Model: e ❑ Other (specify equipment type and model. in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronle"Titre 1✓eak Betector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and r. Model: Model: Model: Model: Model: Model:' - Model: todel in Section E on Dispenser ID: 0 Dispenser Containment Sensor(s). Model. &Shear Valve(s). ❑DispeContainment Floats and Chain Dispenser ID: 0- Dispenser Containment Sensor(s). Model: %Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(. 10 ❑Dispenser o - -- *If the 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 Plan showing the layout of monitoring a uipment'For any equipm t capable of generating such reports, I have also attached a copy of the repcheck all t t apply ;;1 System set-up1 Alar history report ay -l Technician Name (print): J (. Signature: Certification No.: 6d� (o yLicense. No.: _433159 Testing Company Name: _B. Z. Service Station Maintenance Site Address: _630 Houston Street Monitoring System Certification Phone NoA_916_)_371-2380 C W. Sacramento, CA 95691 Date of Testing/Servicing:�2 Page i of 3 03/01