COMPLIANCE INFO 1987 - 2007 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By A 11Jurisdiction$ Within the State of California Aurhoriry Cited: Chapter 6.7,Health and Safety Code: Chapter 16, Division 3, Title 23. California Code of Regulations 'rit rt must be prepared Thu form mustrued to con&document testing and insidof monitoring equipment. of this form must be provided to the rami: for each monitoririne system control panel by the technician who performs the work. A Copy syPtem c wucr/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 Information Bldg.No.: Facility Name: a... 4 Site Address: /IZyu (.t)t6� frr ine w� City: Sd124k-�y _ Zip: wh Contact Phone No.: ( g Facility Contact Person: K )9y8—8 f Make/ModelofMonitoring System 10 rh�'A DLC gOoD DateofTesting/Servicing! /'/jog. B. Inventory of Equipment Tested/Certified ChKk the a ro nate boxes to indicate i "OK t YI ment Inf cudlsrrrice0: Tank ID: T r't%Mry bs Tank IV:—T-- un 0 In-Tank Gauging Probe. Model: NIA.Jr . M In-Tank Gauging Probe. Model: B'Annular Space or vault Sensor. Model: Q'Annular Space or Vault Sensor. Model: .0'Pipi ng Sump/Trench Sensor(s). Model: la-oiping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Elecoonic Linc Leak Detector. Model: O Electronic Linc Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: O Other(specify ur t type and modd in Section E On Pae 2). 0 Other cif c ui mem type and model in Section E on Peet 2), Tank ID: Tank ID: O In•Tsnk Gauging Probe. Model: D In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: O Piping Sump/Trench ScrtWs). Model: 0 Piping Sump/Trench Sertsor(s). Modcl: 0 Fill Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: O Mechanical Line Leak Detector. Model: CI Electronic Linc Leak Detector. Model: U Electronic Linc Leak Detector. Model: O Tank Overfill/High-Level Stnsor. Model: 0 Tank Overfill/High-Level Sensor. Model: O Other(s cif ui merit a and model in Section E on Pagc 2). O Other(s cif a tai rtunt t c and model in Settlor E onPa"2L_ DispenserlD: �� DlspenserlD: y-C, - 0 Dispenser Conrammcnt Sensor(s), Model: 0 Dispenser Containment Sensor(s). Model: A`Shcar Valvc(s). XShear Valve(s). ZDupcnser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID. Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispense Containment Scnsor(s), Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floot(s)and Chains . O Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 0 Dispcmcr Containment Sensor(:). Model: 0 Dispenser Containment Senzor(s). Model: 0 Shear Valve(:). 0 Shear Valve(s). t ❑Dizpcnur Containment Floa s)and ChaiMs). _=j0 Di set Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every rank and dispenser at the facility. C. CertiFreation -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. rennufacturers' 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,I have also attached a copy of the report;(chrck alf rhpr apply): 0 System set-up D AIS history report _ Technician Nanta(print): a 'I Signature:,a Certification No.: 27109-04YZ5 License.No.: Testing Company Name: s Phone No.:(, M ) 464-8333 Site Address: Date of Testing/Servicing: V lgP�lOL Page I of 3 03/01 Monitoring System Certification