COMPLIANCE INFO_1988-2007 - Laserfiche WebLink

Home Browse Search

MONOORING SYSTEM CERTWWTION For Use Rv All Jurisdictions Within the State of California Authority Cited: Chapter 6. 7, Health and Safen> Code;- Chanter 16, Division 3, Title 23, California Code of Regulations This form mast 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 Information � Facility Name: f4A Bldg. No.: Site Address: - cl -',2'C' L- /-A- /— 4Ar City: 4AmoZip: Facility Contact Person: 6,,1 6� f- 4 0 L 4 Contact Phone No.: ( ) Make/Model of Monitoring System: j!CCJ Date of Testing/servicing: -LZ1 1 1 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to fudicate specific eaniument issued Dispenser- ID: ❑ Dispenser Containment Sensor(s). ❑ Shear valve(s). ❑Dispenser Containment Floats) and i Model: Dispenser ID: ❑ Dispenser Containment Sensor(s Ct Shear Valve(s). ❑ Dispenser Containment Floats) and Model: *If the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility. C. Certification - I eertify that the equipment identified in this document was inspeeted/servieed in aceordanee with the man"€actus ers, guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equi nt. For any equip capable of generating such reports, I have also attached a copy of the report* h ck al„l that apply): System set-up his spot t Technician Name (print): ,} 7 ec: /"Otf Signature: Certification No.: 5 Z `r License. No.: Testing Company Name: �lZ l� r ld'� ®apt�s,�r� Phone No.: ( �1C ) L(G t I - y Site Address: /00 % d C>j .4, Date of Testing/Servicing: !` ZIIL/ CY Page I of 3 Monitoring System Certification 03/02 L3' -Tank Gauging Prof. 'pular Model: }iYi%. ?'O - r4g� ( _Tank Gauging Probe. Model: - Y.')"'?C' -/C9 ; Space or Vault Sensor. Model: e�)7!� Y 1 �� tt.nQ 1 uiar Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: L' j`i - 2 t5 Pipmg Sump / Trench Sensor(s). Model: ® Y:7 6 ~• Zet ❑ XSump Sensor(s). Model: _ _ C3 PH Sump Sensor(s). Model• --! Mechanical Linc Leak Detector. Model: jr %1% C ®'Mechanical Line Leak Detector. Model: 5 — ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. .'Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s e . ment and model in Section E on Page 2). ❑ Other (s ec' 22uiLment = and model in Section E on La e 2). Tapit IID:? LD' C_.S a L-- Tank AJ: 05n -Tank Gauging Probe. Model: _, ,7 i� 1C1 - d612 ❑ In -Tank Gauging Probe. Model: ,pular Space or Vault Sensor. Model: 6?9rr �d - =l'+O ❑ Annular Space or Vault Sensor. Model: Ld Psping Sump / Trench Sensor(s). Model: `t 72W 2aY ❑ piping Sump / Trench Sensor(s). Model: Ll M Sump Sensor(s). Model. ❑ Fill Snmp Sensor(s). Model: Mechanical Line Leak Detector. Model: � �? /hZ!- !- - ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- ❑ Tank Overfill / High -Levet Sensor. Model• ❑ Tank Overfill / High -Level Sensor. :Model: ❑ Other (ged ecgupment type and model in Section E on Pa e 2). El other ( ui nt = and Model in Section E on er ID: I C -Z- ispenser Containment Sensor(s). Model: Cj 7 f� t4 - E^ 41 J Spenser Containment Sensor(s). Model: Gl f ` fir® _ �e Shear Valve(s). Shear Valve(s). ❑ DispSnscr Containment Float(s) and Chain(s). U Dispenser Containment Float(s) and Chain(s). enser 'Spenser si - D' Containment Sensor(s). Model: 0 7 `i 210 Zbzf Dispeu= 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 Containment Sensor(s). ❑ Shear valve(s). ❑Dispenser Containment Floats) and i Model: Dispenser ID: ❑ Dispenser Containment Sensor(s Ct Shear Valve(s). ❑ Dispenser Containment Floats) and Model: *If the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility. C. Certification - I eertify that the equipment identified in this document was inspeeted/servieed in aceordanee with the man"€actus ers, guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equi nt. For any equip capable of generating such reports, I have also attached a copy of the report* h ck al„l that apply): System set-up his spot t Technician Name (print): ,} 7 ec: /"Otf Signature: Certification No.: 5 Z `r License. No.: Testing Company Name: �lZ l� r ld'� ®apt�s,�r� Phone No.: ( �1C ) L(G t I - y Site Address: /00 % d C>j .4, Date of Testing/Servicing: !` ZIIL/ CY Page I of 3 Monitoring System Certification 03/02