COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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ON RING SYSTEM C'E TSF TI Tor Use 6� Ah`Jurischctions It ithin the State nfCa1i1b nia AECENED Authorily Citecl: Chapter 6. 7, llecillh WOSbfery C"ocle; C alter 16, Division 3, Title 23, California Code v1'Rc,ulntici11s This form must be used to document testing and servicing of monitoring equipment. A separate certifh�tPonlo r,7nuist be prepared for each monitoring system control panel by the technician who performs the work. A copy o ti i o ip, t d to the tank system owner/operator. The .owner/operator must submit a copy of this form to the local ab 'N U 59t ms within 30 ays of test date. P R ,i,/SEitIIGE A. General Information Facility Name: Bldg. No.: Site Address:aEEl2 tlJc� �� C2fa t City: Zip: Facility Contact Person: F ji (, Contact Phone No.: (OkOCA Make/Model of Monitoring System: L nC.On 1DQ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate_ boxes to indicate specific equinment insnected/serviced: Tank ID: T}' I Dispe r ID: Tank ID: ❑ Dispenser mment Sensor(s). Mod IZ in -Tank Gauging Probe. Space or Vault Sensor. Model: In-Tank Gauging Probe. Model•Annular Sump / Trench Sensor(s). Model:ELn� Model: (JL Siping �PAnru.11arSpace or Vault Sensor. Model:Piping ❑ Shear V, s). ®� _ ❑ Shear Valve Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: jzrMechanical Line Leak Detector. Model: FX IV Pf Mechanical Line Leak Detector. Model: iXF N ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e uipment type and model in Section E on Page 2). ❑ Other (specify equipment ty a and model in Section E on Pae 2), Tank ID: _.`� Tank ID: In -Tank Gauging Probe. Model: I -Ar- b ❑ In -Tan auging Probe. Model: Annular Space or Vault Sensor. Model: E. L`� ❑ Ainular Spac Vault Sensor. Mode Piping Sump /Trench Sensor(s). Model: 4 -tea ❑ Piping Sump / Trenc m sor(s). el: ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: _ ❑ Fill Sump Sensor(s). Model: Model: ) j \1 [� El Mechanical Line L etector. del. ❑ Electronic Line Leak Detector. .. Model: ❑Electronic eak Detector. Mode . ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank erfill / High -Level Sensor. Model: ❑ Other (s ecif a ui ment ty a and model in Section E on Page 2). _ ❑Other (s (specify ui ment a and model in Section n Page 2) a111 DDpenserDenser U> jJ f rnDispenser Containment Sensor(s). Model:Ill S ispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) and Chain(s). Dis user ID: Dispe r ID: ❑ Disp Containment Sensor(s). Model: ❑ Dispenser mment Sensor(s). Mod ❑ Shear Valve s . ❑ Shear Valve(s). ❑ Dis enser Containment Chain(s). ❑ Dis enser Containment Flaat d Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Con ent Sensor(s). Mode . ❑ Dispenser Contai rent Sensor(s). Model: ❑ Shear V, s). ®� _ ❑ Shear Valve ❑Dis enser Containment Floats) and Chain(s). ❑ Dis enser ontaimnent 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equip ent. For any equip nt capable of generating such reports, l have also attached a copy of the the report; (check all tha! apply): ystem set-up rm histo report Technician Nannie (print): ��IJV ��V 3-4) 3ignatur : Certification No.: License. No.: .33a `% - U 7' r3T- t 64 -.1674? Testing Company Name: �l- Phone No.: Site Address: a 2 Date of Testing/Servicing: 0 / / Page I of 3 Monitoring System Certification A Results of Testing/Servicing 03/01