COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, 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. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Info /rti)on Facility Name: Site Address: Bldg. No.: ala City: Zip: 95'eyo Facility Contact Person: A&, Contact Phone No.: (,%79 ) T154-/!Yt Make/Model of Monitoring System:% Sr3$O Date of Testing/Servicing: // / ,l /ol B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauioment insnected/secviced: Tank ID: Tank ID: In -Tank Gauging Probe. Model: A In -Tank Gauging Probe. Model: kr% Annular Space or Vault Sensor. Model: 0109 4 Annular Space or Vault Sensor. Model: v 4499 41 Piping Sump / Trench Sensor(s). Model: iOK 'P Piping Sump / Trench Sensor(s). Model: �✓�� ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Off 4ff Mechanical Line Leak Detector. Model: Zctx�> Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: #1 Tank Overfill / High -Level Sensor. Model:( (OC,/ '47 Tank Overfill / High -Level Sensor. Model: ❑ Other (saiLl Equipment type and model in Section E on Page 2). ❑ Other (specifX 2guipment t= and model in Section E on Page 2). Tank ID: _ Q 1 Tank ID: '4p In -Tank Gauging Probe. Model: RAW I ❑ In -Tank Gauging Probe. Model: -T Annular Space or Vault Sensor. Model: O4C9❑ Annular Space or Vault Sensor. Model: R Piping Sump / Trench Sensor(s). Model: WK ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 4 Mechanical Line Leak Detector. Model: X X„) ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: .E] Tank Overfill / High -Level Sensor. Model: /UEi ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s i ui ment t e and model in Section E on Page 2). ❑ Other (specify ui ment tXEe.and model in Section E on Pa&e 2). Dispenser ID: �-1 Z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: . Shear Valve(s). // ❑ Shear Valve(s). Dis enser Containment Float(s) and6hain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 141Y Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: - ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 0 ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). •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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all 14at apply): System set-up Alarm hi �+y report Technician Name (print): �Signature: _ Certification No.:�License. No.: Testing Company Name:Ji,� *ro � A' /1 t. Phone No.:(ary ) !-po Site Address: l -S 116A& e- q -16a Date of Testing/Servicing: // /7-1 / en Page 1 of 3 03/01 Monitoring System Certification