COMPLIANCE INFO 1999-2006 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the.State of California Authority Cited Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of moititoring equipment. A senarhie certification or retort must be prepared for each monitonttg"system control panel by the technician who performs the work. A copy of this form must be provided 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 Facility Name: Site Address: _ Bldg. No.: may: $7acKTW/ 10, Zip: q9e3`3 Facility Contact Person: Contact Phone No.: (_� Make/Model of Monitoring System:y1: 'i �i'( Rs r ::tZ S=3Sf69— Date of Testing/Servicing: g / z2 B. Inventory of Equipment Tested/Certified Check the appropriate hoses to Wirate sPeeinc equipment h'sped Taynkk ID: I — l2LrCstc�iL..,{ $ Tank Gauging Probe. Model• C;trmular Space or Vault Sensor. Model: @'Piping Sump / Trench Sensor(s)- Model ❑ Fill Sump Sensor(s). Madel Line Leak Detector. Model: mechanical ecuonic Line Leak Detector. Model• ❑ Took Overfill / High -Level Sensor. Model: n rut.,.. i�ifv emrinment ry x, and model in Ta tSk In il�ju Tank Gauging Probe. Z�I �Ayn°ular Space or Vault Sensor. i1Piping Sump/ Trench Sensor(s). • Fill Sump Sensor(s). ❑ /Mechanical Line Leak Detector. ,Ip ttecttonic Line Irak Detector. ❑ Tank Overfill / High -Level Sensor. Model: Modes: PL F D - Model: 7mlkaj Model: Model: Model:.O —aa2 Model: andel in Section E on Page 2) Dispeo m: 1— L ❑ Dispenser Containment Sensods). Model: i35rea Valve(s). PT t'.nnrainment Floadsl and Chaintt Tank ID: 7 " > tc a-T&Tank Gauging Probe. 01 Ovular Space or Vault Sensor. a-V$ing Sump / Trench Sensor(s). (3 Fria Sump Seasons). ❑ Mechanical Line Leak Detector. nic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Spam or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). U Mechanical Live leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ other (specify equipment type and Model: Model: Model--- Modek Model: Model-.�/o'� O Model: model in Section E on Page 2). Model: Madel: Model: Model Model: Model• Model: Dispenser ID: ` - a I7 Dispenser Containment Senst r(s). Model: drShear Valve(s). t>�� Die ID: ❑ Dispenser ConrainIt Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model- CrShear Valve(s). ❑ Shea Valve(s). l7 Dismun Containment Float(s)and Chmn(s). Drbperisee'D Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Chear Valve(s). ❑ Shear Valve(s). �,.�---� ^.......:......... tn..s.r.t �.,,s n,a:,,r�t ❑ Dispenser Containment Float(s) and C6ain(s). •If the facility contains more tanks or dispensers, copy this form, Include information for every tank and dispenser at the C. Certification - I certify that the equipment identified in this document was impeeted/ser feed in actor lauee with the manuLaokurErs' 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 eqpgament. For any equtpaeut capable of generating such reports, I have also attached a copy of the report; (check as that apply): U System set-up ltts ry re O Technician Name (print): /91_aI Z .4 t l6�tR tJ Signature: ��.-Y Certification No.: License. Na: gni'77o Testing Company Name: 4fF �i O,a✓� ��G S/DiJ ±,42Ltil-, lk-�5r, 4Phone Site Address: -J ©`j A-t '�KT_bfj Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification