COMPLIANCE INFO 2009 - 2015 - Laserfiche WebLink

Home Browse Search

w � MONITORING SYSTEM CERTIFICATION For Use Bp All Jurisdictions Within the State of California Aurhorin•Cited:Chapter 6.7. Health and Safety Code;Chapter 16.Division 3. Tide 23. California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or repon must be Prepared for each monitoring system control panel by the technician who performs the work. A copy of this I'onn must be provided to the tank system owner/operator. The owner/operator must submit it copy of this form to the local agency regulating UST systems within 30 days of test date. A. General lnforfnatioR. ( (�� rO\ �Facility Name: "'�`^ ' Bldg.No.:Site Address: �tity: Zip: Facility Contact Person: Contact Phone No.:( 7_�) e, Make/Model of Monitoring System: 'AL3 Date of Testing/Servicing: /J_/z�/za? B. Inventory of Equipment Tested/Certified Check thea ra nate buses w indicates eripe ui merit ins vted/scn'ica-0: "rank ID: 'tank ID: Z X In-Tank Gauging Probe. Model: .� In-Tank Gauging Probe. Model: .9 Annular Space or Vault Sensor. Modtl:_YA Ld Annular Space or Vault Sensor. Model: yzD A Piping Sump/Trench Senwr(s). Model: W Piping Sump/Trench Sensor(s). Model, ZO9 w30 U Fill Sump Sensor(sl. Madel: k19 VQ* 70q f-Fill Sump Sensar(s). Model: ✓.dIMI RA-W`/ U Mechanical Linc Leak Detector. Model:__ U Mechanical Linc Leak Detector. Model:—� �Elocuni nic Line Leak Detector. Model: YF Y"•'cLr WElecuonie Line Leak Detector. Model: ✓ U Tank Overfill/I ligh-Level Sensor. Model: U Tank Overfill/ffigh-Level Sensor. Model: U Other(s if\equipment is and model in Section Fin Page 2). U Other(s cif\equipment tv and model in Section E on Page 2). Tank 1D: --��-- Tank IU: U in-Tank Gauging Probe. Jtodel: ❑ In-Tank Gauging Probe. Model: U Annular Space or Vault Sensor. Model:_ '/z0 ❑ Annular Space or Vault Sensor. Model: U Piping Sump/Trench Sensor(s). Model: VXZ e/ U Piping Sump/Trench Sensorls). Model: U Fill Sump Sensor(s). Model: !'Z %c2 V U Fill Sump Servants). Model: U Mechanical Line Leak letecmr. Model: U Mechanical Line Leak Detector. Model: U Elemronic Line Luk Detector. Model: e60 U Electronic Line Leak Detector. Model: _ U Tank Overfill/lligh-Level Sensor. Model: U Tank Overfill/l ligh-Level Sensor. Model: _ U Other(specifv equipment tvne and model in Section E on Pae 2). U Other(s "ifs a ui ment t\ N and model in Section E on Pace'). Dispenser ID: /Ili,- Z- Dispenser 11): -37 Af Dispenser Containment Sensor(s). Model: .�Dispenser Containment Scnsops). Model: 8 }d Shear Valvc(s). A Shear Valve(s). J Dispenser Containment Floats)and Chain(s). J Dispenser Containment Points)and Chain(s). Dispenser to - 1 Dispenser ID: d^SDispenser Containmcnl Scnsoro). Mndcl: LQQ i �' A Dispenser Containment Scnsorls). Model: If&ZG8 0`>< gShear Valvc(s). XShear Valve(s). J Di riser Containment Floats)and Chain(s). U Dispenser Containment Floausl and Chain(s). Dispenser ID: Dispenser ID: /Z- �DispenserContainntentSensor(sl. Mulct: 7L1g' -y . Dispenser Conhunment Sensor(s). Model: Z0Z LC/ 46 Shear Valve(s). Of Shear Valve(s). LIDispenser Containment Floats)and Chain(s). U Dispenser Containment Floatts)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 -1 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. ianufaclurers' checklists) necessary to verify that this information is correct and a Plot Plan showing the Layout of monitoring equipment Far any equipment capable of generating such reports,1 have also attached a copy or the report;(checkalt Jha r apply): .2ISystem set-up ,®Alary(historn,�reP9�'/J/ - TechnicianNamelprint): LJ94&=Anr_S Signature:_ .-Ver^—' -w_�____ 7 Certification No.: 32 / License.No.: _ .S_�r/t 3 (/L Testing Company Name: Phone No,(_Pe" � � �e�'s3'✓�- Site Address: ?16 � Date of Testing/Sen•icing:1� I�yl�' Page I ora 03/01 Monitoring System Certification