COMPLIANCE INFO_2013 - 2018 - Laserfiche WebLink

Home Browse Search

t�1l}"i yew.?=n'1 • t • 1 . t' a 1 T ! ! 11 �. ° • y F- Trk " F�7n1}'!�*'•)� 1 • ! f f s ! 1 i • f 1>, r� ' y,+1°_� �Y I • 1 `11 , e �� ! +:: ��, t ", / 1 1 • • a ! / O 1 1 : i'y rf 9y ; / fT 1 1 • 1 T • ! 1i ,y f;':..ry N, Y' �• I. Appendix VI , (Copies of Monitoring System r reification form and UST Monitoring Plot Plan available at hftoJ/www.waterboards.ca.gov.) M1, NITORING SYSTEM CERTIFICATION Far Use By All Judsdlctlons Within the State of California Authority Cited. Chapter U, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 0 ! This form must be used to document e::ing and servicing of monitgring equipment. A separate certification or report must be prepared for , each monitoring system control pane i) the technician who performs the work. A copy of this form must be .provided to the tank system owner/operator. The owner/operator r is( submit a.copy of this form to the local agency regulating UST -systems within 30 days of test date. A. General Information L, ) ` Facility Name: f 1 1� lN y Bldg. No.: ,rr�� Site Address: ! ,� �� f�� I City: �SWA ni Zip- p" t �Jl 6 Facility Contact Person: �� - _ Contact Phone No.: c2if J & �rJ Z4_1 8 Make/Model of Monitoring System:,; L.�� „n,�� ,� tom) e Date of Testing/Servicing: B. Inventory of Equipment Tested/Certifir. Check the appropriate boxes to Ind, It rte: specific equipment inspectedlservlced: Tank ID: .S F ZV In -Tank Gauging -Probe. Er Annular Space or.Vault Sensor. a,• Pip[ng.Sump./Trench Sensor(s). ,GY'FIII Sump Sensor(s)_ 0. Mechanical Line,Ceak Detector. 0" Electronic line Leak Detector. ,d' Tank Overfill 1 High -Level Sensor. ❑ Other- specify equIpment type and t7,-irr-i'anKtjaugmgrrone. --- ❑ Annular; Space or Vault. Sensor. ❑ Piping Sump / Trench Sensor(s). 0 Fitt, Sump Sensor(s). ❑ Mechanical Line Leak.Detector. -t7-Electronicl-Ine-L-eak-Mector-- '- -❑ Tank Overfill / High -Levet Sensor. ❑ Other.(spspecify equipment type and n � ..Dispenser ID: ❑. _Dispenser Containment Sensor($). ❑-ShearValve(s). Mt) !i: tie/- , 11 - f V, Mo )I: Mon tl: Mc [1 :I: f '"', Moa :I: —i!, dei i i le:tion E on age 2)- Mct. 1: /tea �_ MCC I:, F 'a' r MCC h - 169 MCI I: MCI 1:_.��.. lel til e:iion Eon.Pag2e 2). Moj ❑ lJispertser containment rroatts) and e;nainl; Dspenser (Dc _ 0 Dispenser Containment Sensor(s). Mai :- 0 - Shear Valve(s). Tank ID: '- -"'Dispenser°ConCalrimentFbat(S) antl'Gttsin(s D I)is enserConta)nment Floats andChal s). lSisperiser.tb: ❑ In -Tank Gaug ng Probe. Model: i 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Sensor(s). Model; e ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Moder:. D Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor_ Model: ❑ Other Lspeclfequipment a and model in Section E on Fac Tari ,Di License: No.. ��C�%� ��f� l�_l'4�"f'-`? `0 In=TfiikGauging`Proba. Model: - i ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: D Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 'TJ-'Electronl� L7Pse-teakDetectar- ----Mtf�l`•------ 0 Tank Overfill I High -Level Sensor, Model: ❑ Other (specify equipment type and model. in. Section on Pag Dispenser lb: --- -- - - - ------ t D_ Oispen,5er Cotai>)gtetlt Serrsgr(sj., Model: D Shear Valve($). ❑— Dispenser Containment Float($) and Chain($). - Dlspenser )D - '❑ Dispenser Containment Sensor(s)_ Model: -❑ Shear Valve(s). 1 2/2I/07 2'd at C9T9t160ZT s-1040elu00 Al a4113 d00:i?T ET Li? cla3 Dispenser. IM, 0 Dispenser ConiainmenFSerisor(s). MocN C Dispenser Containment Sensor(s). Model. + :L�Srieat�vatue(s)._..._-----D-SIieaWalJe(s) - .. .. .... T7. Dis nser Containment Float . and.Chain :. ❑ Dispenser Containment Fictaksland Cham s .. . *ff the facility contains more tanks ordispenser -y this,form Include information for every tank -aril dispenset_at the far�ll y,, ....... . C. Certification. -. I certify -that the •equi.: lent Identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certiflcati: N information (e.g. manufacturers' checklists) necessary to verify that this Information is correct and a Piot Plan showing the layout of r1 nitoring equlpment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply, 1, ❑ System set-up 0 Alarm history re ort qq Tecfarticlan Nar eIprintj:. . 4�r� Ixt (.re Signature: ' GortificatIonNo.: License: No.. ��C�%� ��f� l�_l'4�"f'-`? Testing Company Name: f,l ✓y _ - Phone No.:( % Cq), 16 1 lt'- 3 f Testing Company Address: S� : % i al'Ls+r +. l�/. (�f / � in h (fi10- Date of Testing/Servicing: y14_l / Monitoring System Certification Page 1 of 4 1216r 1 2/2I/07 2'd at C9T9t160ZT s-1040elu00 Al a4113 d00:i?T ET Li? cla3