COMPLIANCE INFO_2002-2008 - Laserfiche WebLink

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RMU For Use By All Jurisdictions Within the State of California Authority �ited. Chapter 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofP?N#1t*J0j!s2003 I 1 C6I This forth must be used to document testing and servicing of monitoring equipment. A Leparate certification or Ft for each mojgtorin$Ustent control panel by the technician who performs the work. A copy of this form must 1p system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating U y % eni'MM 0 days of test date. A. General Information Facility Name: ( ),U2 tri Site Address: C1 10 ?1 C0 t.t.City: Facility Contact Person: ST!EU*lEA) Sr- E r 0-1 Contact Make/Model of Monitoring System: Ucjsoet-4-x MLS,19,C) B. Inventory of Equipment Tested/Certified Check the appronvinte Imes to ind"to an ifip PA Bldg. No.: — Zip: - Phone No.: (3 t1 9 ,1 -,I;j 00 Date of Testing/Servicing: A3 1,2_4flAa Tank ID: Tank ID: 9 In -Tank Gauging Probe. Model: /Aoq3 U In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 744.4CIO - q2 0 U Annular Space or Vault Sensor. Model: A Piping Sump / Trench Sensor(s). Model: Wit( 7 - 4 v!% U Piping Sump / Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. Model: 44 Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: U Tank Overfill / High -Level Sensor. Model: U Tank Overfill / High -Level Sensor. Model: U Other (specify equipment and model in Section E on Page 2). Ll Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: Ll In -Tank Gauging Probe. Model: U In -Tank Gauging Probe. Model: U Anrftdar Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: U Piping Sump / Trench Sensor(s). Model: U Fill Stunp, Sensor(s). ., - Model:0 Fill Sump Sensor(s). Model: LJ Mechanical Line Leak Detector.- Model: Ll Mechanical Line Leak Detector. , Model: U Electronic Line Leak Detector. Model: U Electronic Line Leak Detector, Model: U Tank Overfill / High -Level Sensor. Model: U Tank Overfill / High -Level Sensor. Model: U Other (specify equipment type and model in Section E on Page 2). U Other (specify equipment type and model in Section E on Page 2). Dispenser ID: wy3 Dispenser ID: Dispenser Containment Sensor(s)- Model: 71 4,3Cq0-&t�1 U Dispenser Containment Sensor(s). Model: U Shear Valve(s). U Shear Valve(s). U Dispenser Containment Float(s) and Chain(s). U Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: U Dispenser Containment Sensor(s), Model: U Dispenser Containment Sensor(s), Model: U Shear Valve(s). U Shear Valve(s). U Dispenser Containment Float(s) and Chain(s). U er Containment Float(s) and Cham(s). Dispenser ID: Dispenser ID: E3 Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: U Shear Valve(s). Q Shear Valve(s). Ql)iser Containment Float(s) and Chain(s). U DiNenser Containment Float(s) and Chain(s). ,it me tacitity 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 ins 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 equipment. For any equipment capablef generating such reports, I have also attached a copy of the report; (check all that apply): System set-up 21 rm oj report 14 Technician Name (print): Sdo P&adoW Signature: 40 IAIA� M 8 1 Certification No.: - a 6--1000413— License. No.. 'A 6 Testing Company Name: A 0 S I&! _o_wwm EaT Phone NojY01_) fsa(-0708 Site Address: _VQ� -0- . Date of Testing/Servicing: Ll 20C)5 Page I of 3 03/01 Monitoring System Certification