COMPLIANCE INFO_2008-2009 - Laserfiche WebLink

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t. s l'' c 6t,'.4/l.lrrris�lictions flilhir�Ilre,S'Ia[cof'ColiMOM ' - FUNG SYSTEM u I trt/x�rih%C'i1�d: (.'hap/cr 6.7 l/i:'u e ul&S feh'C'o(le; Chapter 16. Division 3, Tii/e 73, C'alifbrnia Code�f'hc;�rzila/ion's, This forni must be used to document testing and servicing of monitoring equipment. A separate certification or report mast be prepared for each monitoring system control_panel by the technician who performs the work. A copy of thi, yiq$t be iovidecL�o _. the tank system owner/operator. The owner/operator must submit a copy of this form to the local agen �it�l�it^i�g�(l� � t'i� within 30 days of test date. A. General Information .SUN 0 6 2008 Facility Name: /VE1� > T �NEt,I� /C>®3 Bldg.No.: Site Address: (/✓• ,4/�/t� 57 City: ZZO / E N�-. I i ' '� .9 VtIH P F. ;� fs RVICES Facility Contact Person: de-71A Contact Phone No.: ( )`'':: Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check tbe appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 87- y�T � Tank ID: H In-Tank Gauging Probe. Model:— = R( In-Tank Gauging Probe. Model:' M461 t- 21 1$ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: y<�� A Piping Sump/Trench Sensor(s). Model: IN Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump SenSOr(S). Model: ❑ Fill Sump Sensor(s). • Model: JIQ,Mechanical Line Leal:Detector. Model: 17'74AZOW A-Mechanical Line Leak Detector. Model: S-rP•1?LD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(s.ecify e ui meat type and model in Section E on Page 2). Tank ID: Tank ID: q/ ❑ In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: Ut Piping Sump/Trench Sensor(s). Model: ZO ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: R Mechanical Line Leak Detector. Model:FK- o V ❑ Electronic Line Leak Detector. . Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sgecifl a ui rnent ty a and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: t 'f 2 Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: )N Shear Valve(s). IN Shear Valve(s). Iii Dispenser Containment Float(s)and Chain(s). &Dis enser Containment Float(s)and Chain(s). Dispenser ID: 3'F`f Dispenser 1D: 19-4-111) ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: IQ Shear Valve(s). IQ Shear Valve(s). J.Dispenser Containment Float(s)and Chain(s). ®.Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5+(P Dispenser ID: i I CA-I-— LI Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: A Shear Valve(s). 15 Shear Valve(s). .Dis enser Containment Float(s)and Chain(s). I ® 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,l have also attached a copy of the report;(check all that apply): &:ste s t- IIarm history report Technician Name(print):7lw .,te ;, n Signature: �" ,� p zee -& 5233a-7 U 7- Certification No.: 893 License.No.: tjITj .;da -J&,7& Testing Company N•�arne: 4W640,4 _ , 1 Car. Pllone No.:( )74-1 - 60,2- Site '`)'4 -/ - to0,ZSite Address: 1 r PI/ Ic�At`4t-4 ;nT( Date of Testing/Servicing: 5-/ lZ_/®8 Page I of 3 03/01 Monitoring System Certification A Results of Testing/Servicing