COMPLIANCE INFO 1995 - 2008 - Laserfiche WebLink

Home Browse Search

MO NARING SYSTEM CERTWI ON f For Use By All Jurisdictions Within the State of California Authority°Cited Chaptar 6..', Health and Safely Code;Chapter 16,Division 3, Title 23, California Code of Reguiations This form rima be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control parcel by the technician who performs the work. A copy of this form must be provided to the tank; system owner/operator. The ownerlooerator must submit a copy of this form to the local agency regulating UST systerns within 34 days of test date. A. General Information Facility Name: 1:a Bldg.No.: Site Address: 2YW City:,// tom Zip: Facility Contact Person: � _._.4 a-- _ c yr Coittact Phone No.:t 1,0C (o'Jr- Malce/Model of Monitoring System: ? + re Com `t Date of TestinglSetvicing: 3 B. Inventory of Equipment Tested/Cerffed Check the a ro riate basei to indicate 2edric ratserviced l`3` _Taemk CmogingPrnlae. Madel: d� O t4G° Tasxlc Gatagzng Prate. 11ade1: 7_C� O tJ�Gd i�Annnlar Spate or Vault Sensor. Model: V � Annular Space or V auh Sensor. Model: �' !!c !GD Piping Sump 1 Trrnch Sensor(s). l�fodel: 1� Z r Z� 'ep` ErNping Sump/Trench Scusor(s). Model:/aP7D 5 S 3fi�a�n ❑ F'ill Sump Sensor(s). Model Sump Sensor(s). :Model: 8"NlIcchanical Line Leak Detector_ Model: i f'Yld� echanical Line leak Detector. Model: L ❑ Electronic Line Leal:Detector. Model: ❑ Electrotuc Line Leak Detectar. Model: ❑ Tank Overfill r High-Level Sensor. Model: ❑ Tank Overfill.f High-Level Sensor. Model: ❑ Other(s ecifyai tnen[ and model in Section E on P e 2). ❑ Other(specify ui trent and model in Section E on Pae 2). Ta 'ED: u.L Tank ED: Tank Gauging Probe. Model: G "0 ❑ In-Tank Gauging Probe. Model: molar Space or Vault Sensor. Model:��2 ❑ Annular Space or Vault Sensor. Model: iJ Fiping Sump 1 Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). ]Model: ❑ Fill Sump Sensor(s). Model: E' cclra nical Line Leak Detector. Model: EO 2a 0 0 E3 Mechanical line Leak Detector. Model: ❑ Electronic lane Leak Detector. Model: ❑ Electronic Line leak Detector. Model: Ll Tank Overfill l High-level Sensor. Model: 13 Tank Overfill f High-Level Sensor. Model: ❑ Other(soeciLv uipment Lyin and model in Section E on Pa a 2). ❑ Other(specify ip ynt type and model in Section E on Pate 2). Dispenser 1D: 1 Dispenser ID: 5 'T ❑ Dispenser Containment Sensor(s). Model: "❑ji)spcnser Containment Sensor(s)- Model: VEDispfnwr hear Valvc(s). Z Shear Valve(s). Containment Float(s)and Chain(s). O/DisgEnser Containment Floar(s)and Chain(s). Dispenser ID: ` Dispenser ID: ❑ spenser Containment Sensof(s). Model: ❑ Dispenser Contaiumuent Sensc s). Model: 7ShearVaive(s). B� hearValve(s). Dis ContammentRoat(s)and Chain(s). F46ispenscrContainmentFloats)and Chain(s). Dispem ser-ID: Dispenser'ID: ❑ Dispenser Containment Seusor(s)_ Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). IJDispcnscr Containment Float(s)and C'haiu(s). i ❑ Dispenser Conminument 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-l eertity that the equipment ideniriied in this document was in peeted/servieed in aeevrdanee with the nuinu[attur-ers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,T have also attached a copy of the re (ch .k� that apply): ❑System set-up ❑Al his rte rt Technician Name(print): r Signature: Certification Ne.: 5-t License. No.: Testing Company ,m'_ C�•y 7-;;;�-, k, � ( +} A7 5 Phone No.: !"- Roy, Site Address: 0 . Ro 7, f j o s � S0.C; 0 d4 el� k F.�" CIS Date of Testing/Servicing: LL� /_02 Page 1 of 3 tlNGI Monitoring 5 vstem Certification P l!.� QUI APR 0 12003 ENVIRONMENT HEALTH PERM ITISERVICES