COMPLIANCE INFO_2010-2015 - Laserfiche WebLink

Home Browse Search

r . 4 Jun 10 11 01:48p Elite IV Contactors 12094616342 p.3 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available, http:/1www.waterboards.ca.gov.} MONITORING SYSTEM CERTIFICATI )N For Use By All Jurisdictions Within the Slate of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division a ritle 23, Calitomia Code of Regulations This fort must be used to document testing and servicing of monitoring equipment. A separate cei f cation or report must be prepared for each monitoring system control pane( by the technician who performs the work. A copy of this hr i must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating W 'systems within 30 days of test date. A. General information Facility Name: �3 f'c' 6c F Ip. No.: Site Address: ,3 7 �_� 'rG /s9�.�i _ GitY: ��;. — Zip, ,t ll -13: Facility Contact Person: Contact Phone No.: (�.— . C 7 Make/Modal of Monitoring System: _ !% �5 vi �4.� Date of Testingh er using: B. Inventory of Equipment Tested/Certified Check thea ro date boxes to Indicatespecific a of ment In Tank ID. Piping Sump/ Trench Sense ir( L in -Tank Gauging Probe. ).e Annular Space or Vauft Sensor. Model: Mil:1 C Piping Sump /Trench Sensor(s). Model: Fill Sump Sensor(s). Model: *EO C Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: C Tank Overfill / High -Level Sensor. Model: r- i1thar (cnnr•ifv a miinmant tvna and model in Section Eon Paqe 2). Tank ID: I' in -Tank Gau ing Probe. L Annular Space or Vault Sensor. C Piping Sump / Trench Sensor(s): )5, Fill Sump Sensor(s). c Mechanical Line Leak Detector. C Electronic Line Leak Detector. C Tank Overfill / High -Level Sensor. DispenserID: Dispenser Containment Sensor(: Shear Valve(s). user Containment Float s Dispenser 10: ^' C Dispenser Containment Sensors C Shear Valves). p0bispenserContainment Float(s); Dispenser 10: C Dispenser Containme Sensors L Shear Valve(s): er Containment Float(s)a •If thEi facility contains more tanks or Model:. '• ',;�� Model. _ Model: 5— - Model: Model; Model: Model: copy this Tank ID: U in-Tarkdauging Probe. ,k Annular Space or Vault Soma Model: Model: [ir7 Piping Sump/ Trench Sense ir( Model: �❑ Fill Sump Sensor(s). Model: 2fi?i" ,,r7 0 Mechanical Line Leak Detecto Model: ❑ Electronic tine Leak Deteac ir. Model: ❑ Tank Overfill / High -Level Sem: x'. Model: 0 Other (specity equipment tyIie iid model in Section E on PM 2). Tank ID: n Ire -Tank Gauging Probe. Model: u Annular Space or Vault Serwo Model: D Piping Sump/ Trench Sensor( Model: ❑ FII Sump Sensor(s). Model: . ❑ Mechanical Line Leak Detecto Model: a Electronic Line Leak Detector. Model: 7 Tank Overfill / High -Level Scm: a'. Model: 0 Other (specify equipment ty►e nd model in Section E on Pa 2). Dispenser ID: u DispenserGontainmen Seri 3c s:: Model: ❑ Shear Valve(s). ispenser Containment Float(: sand Chains . DispenserlD: '� '-rG— ._ D DispenserContairimentSere st :. Model: ❑ Shear Valve(s). SODIsDenser Containment Ftort(: _.and Chains}. Dispenser ID: t /',% 0 Dispenser Contakurtent Seri sc s). Model: u Shear Valve(s).. ksDisoenser Containment FimM, and Chain(s). ation for every tank and dispenseir : the facility. C. Certification - I certify that the equipment identified in this document was Inspected/swvicet I guidelines. Attached to this Certification Is information (e.g. manufacturers' checklists) necessarf' and ei Plot Pian showing the Layout -.of monitoring equipment. For any equipment capable of general copy of the report; (check alt that app ❑ system set-up ❑Alarm exy rt p , .... { i mature: Technician Name (print): y S.g... Certification No.: Licen— Testing Company Name:' ffl� Phone Testing Company Address: ��55_!✓' �/Z 1 Date of Test monitoring System Certification Pagel of 4 accordance vrith the manufacturers' verify that this information Is correct q such reports, I have also attached a 'P r iuServicing:(� / if//I 12107 2/21/07