COMPLIANCE INFO_2000-2009 - Laserfiche WebLink

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MONI RING SYSTEM CERTIFI .L -T FION E u F D For Use 6v. 111.11tr•isclielions Within the Stale of California ifulhorily C'itecl: Chapter 6.7, Health and Sgfety Code; Chapter 16, DiviSlO17 3, Title 23, California CodeN lye"1la�oo" This form must be used to document testing andel servicing of monitoring equipment. A separate certilU44 QW}/`F9 -} MU )LTh { Pre pat red for each monitoring system control panei-py the technician who performs the work. A copy of this fc i nor i 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: Bldg. No.: Site Address: ZZ_ Sot/+)n City: Zip: Facility Contact Person: Contact Phone No.: (z ® Make/Model of Monitoring System: y _ — a 3Q Date of Testing/Servicing: 1 / ' 1 / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID: T• n ID: In -Tank Gauging Probe. Model: MAU In -Tank Gauging Probe. Model: Amwlar Space or Vault Sensor. Model: t(U'i �1 Annular Space or Vault Sensor. Model: WO-) Piping Sump / Trench Sensor(s). Model: -Z C) ❑ Piping Sump / Trench Sensor(s). Model: 3:! Fill Sump Sensor(s). Model: Ll Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: f _07 'Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank- Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other (s ecif equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ 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: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecif a ui mint !Xpe and model in Section Eon Pa a 2). ❑ Other (sEecify equipment t e and model in Section E on Pa a 2). Dispenser ID: Z —2 Dispenser 1D: f �j ❑ Dispenser Containment Sensor(s). Model: 10fj ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: "2 19 Dispenser ID: 1 4 10 ❑ Dispenser Containment Sensor(s). Model: -2 05 ❑ Dispenser Containment Sensor(s). Model: tai ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: b f C' Dispenser ID: if s Z. ❑ Dispenser Containment Sensor(s). Model: Z OZ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this tonn. 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 Phan showing the layout of monitoring equipmenk For any equipment capia 6fe__oTjeuqrating such reports, I have also attached a_copy of the report; (check all that applv): ❑ S em set-up ❑ AI. - 'story repo Technician Name (print): Felix Ramirez Signature - Certification No.:? License. OTTL # 08-1740 IC 934 -UT Testing Company Name: �i `.- Phone No.: _ L R (. Site Address: q1b -47- oto Date of Testing/Servicing: Page 1 of3 Monitoring System Certification D. Results of Testing/Servicing 03/01