COMPLIANCE INFO 2002-2010 - Laserfiche WebLink

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rI or' t�sc 131+:�IlJur•r•s•rlicvinrr,s• IJ'itlrira tlre,51rr1e gff'crlif�ar•rricr �� tl trlhvr•iA,Cifecl: Chcipler 6 7, Hea/lh arrtl.S'f!kV C'ucle; Clrtrirler 16 Division 3, Tille 23, California Cotle of Re,�;ulutiorr,r This form must be used to document testing and servicing of monitoring egttipment. A separate certificati U 04494 be prepared for each monitoring systern control panel by the technician who performs the work. A copy of this is t the tank system owner/operator. The owner/operator mast submit a copy of this form to the local agente�,,{T�it�il�li � { within 30 days of test date. ,� R� � mro.l J A. Generali formation Facility Name: J d rP r 0 1 f /d� Bldg.No.: Site Address: 'c I r7 1 e7 City: fit + ' .Zip: 2,67--Z&7 Facility Contact Person: S� r Contact Phone No.:(•p Q )_ 'I—�`J'4 Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a i ru riate boxes to indicates tc4 a ui ment ins ectewseroceil: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ in=Tank Gauging Probe. Model: C3 Annular Space or Vault Sensor. Model: . ? _ ❑ Annular Space or Vault Sensor. Model: A.5-Ll Piping Sump C Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model:_ ❑ Fill Sump Sensor(s). Madel:- ❑ Fill Sump Sensai(s)• Madel: Ll 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(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment type and model in.Section E on PaLe 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). Madel: ❑ 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(s2ecia a ui ment a and model in Section E on Pae 2). ❑ Other(specify a ui ment type and model in Section E on Pape Z). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: D Shear Valve(s), ❑ Shear Valve(s). / ❑ Dispenser Containment Float(s)and Chain(s). CI Dispenser Containment Float(s)and Chain(s). 7r Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Ll Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chainfs). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ElDispenser Containment Float(s)and Chain(s). El Dispenser Containment Floats)and Chnin(s). 41fthe tacili€y contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at tine 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,l have also attach d a copy of the report;(check all fhat applF): ❑ Syepm set-up ❑AJarffrJLL5jojj report Technician Name(print): Signature: Certification No.: License_No.: Testing Company Name: l J q 4-0 Phone No.: Site Address: Date of Testing/Servicing: (F3/t?1� Monitoring System Certification Pale 1 of.l D. Results of Testing/Servicing