COMPLIANCE INFO 2000 - 2004 - Laserfiche WebLink

Home Browse Search

FROM :TLM PETRO LABOR FORCE FAX NO. :5629238138 ug. 16 2004 09:15AM P3i7 PST ARCO 9578 PACE 02 MONITORING SYSTEM CERTIFICATION For Ute sy All Jurodictiom Within the S"e of Caljrorhfla Atnhori►,y Coed'Chapter d.7, Health and Suety Code; Chapter m,1xvision 3, Dile 23,Calf min Coda,,f R0gtt/anions This form itlust be used to doc:utnmt testing and servicing of rnonitdting equipment.Aam,J;rrtifiUation Qtr=Z ip at be 2=,tad tgLgach i by the technician who performs the work- A,copy of this form roust be provided to the tank systetit ow&7/01)Mt>r- The owner/oDmtor must submit a copy of thtg f�wm rn the local asmcy Nouleting UST systems within 30 days of teat date. A. GenerallaformntWo Facility Name: _ Bldg,No.: Site Addratos: 0 City, Zip: Facility Contact Person: Contact Phone No.: Mako/Model of Monitoring System: Date of T=41nt/Serviaing: lel— B. 11(lveliltory of EgaipMent TesteWCertffled Chl6ek the k Asa b M Rr Tank III: _ Tank ID: _ D LrTank Gauging Probe. Model: CJ in-Tank Gaugin®Probe, Model: W` ❑ Annular Space or vault Sensw Model:-- ❑ Amuular Space or Vault Sensor. Model: _ ❑ Piping Jump/Troaah Sensor{;), Modcl: ❑ r"g Sump/T ah:h 9cnaor(s)- Model: ❑ Fill Sump Sensor(s). Modol:�~ �. d Fill Surm Sertaor{s). Model: u J U Mechanical Line Leak Detector. Model: a Mechanical Line Leak Detector. Modcl: - ❑ Elowonic Lixte l-eak Detector. Mo&L Q Fleet imc L}ne tacit Doactor Model: Q Tank Overfill/High-Leval Sensor. Model: © 'leak OverAll/wgh-Lovat S=Kw Model: CJ Others ci t end modci lt7 Sccti<wt P an P c 2 Q Ot1w, d equj=gr and andel in Scctio.E on P#V Z . Titak IDr Task ID: ❑ ln•Ta ik Gauging Probe- Model:_ Q In-Tank(ieugmg Probe- Model: ❑ Amulet Space or vauh Sensor. Model: U Annular Space or Vault ScmW- Modal'—_- O Piping Sump/Tmoah 9tnscn(s). Model:T _ ❑ Piping Sump/Trench Sentor(s). Model: Q ,Fill Sump Sensor(s). Model: - 3 Fill Sump Sctlsor(s). MIDI, _ ❑ Mechanical Line Leafs Doo", Model: - _ Q MWhtatical Line Lank JIMEcrnr. Model: D Ele ornic Line i-4ak Detector. Model: Q F-ieef!'6nic Line Lealt Detrotot- Motel: ❑ Tank Overfill/High-Level Sensor, Model: ❑ Tactic Overfill/High-Level Sens-. Model. ❑ Other(weel e i r and model inLacon E oo ❑ Other e i t and mqkI in Section$ P . Dit{rtsittaetr ib: t !� Dtspenwr ID' _ a Dfepm5cr Conmimneut Sensor(;), Model:��,l�i � 1?ittpenstr Containment Sensor(s). Mudel "66a0f; ❑ Shear Valve(s). ❑ shers Valve(R). Q Pivemw Contalnmeat Flo a and Chaff s . ❑ DgVeWer Containment Floa s and Chaff a. DkotoserlD _ DlapawaerID: _ ❑ Dlepenw C,ontafrtment Smmor(a), Model: ❑ DiBpettlerContairimertt Sensor(s). MctdCdel; :] Shear V*e(s). ❑ Shear Vjdve(s)- -aDiapmer Cont advent Floats and(.'hai 9 - ❑ ])Ls Contahtmcof 1!bat(;)and Ch ' s. D6pcnacr ID: 4 mpeawr rD. d Dispenser Containment Sensor(s). Modol:J_ _-- O Disponser•Conteltmrcnt Sensor(R), Model: _ O Sheer Valve(s). d Shear Valve(1). ❑Di Containurvt Flout a and C i s. Q D! Cqntauent F! and 2U644. •If tine facility oonmins mom treks or dispensers,copy thio 113rim Include inibTum ion for awry to*and dlspcata.x ar the hdi ty. C. COrt ft2tion-i certify that the eqW00imt IftedW io tbls doaursettl was laapAetAd,/*r'vieed IN ecsordanee With OW rw 9ftkt arcrx' RaMettrrn. Attached to 0&Cie"ft0m is infbn Utlan (&Z maj%faetaron' cMMWs) oecttteary to verify tical tale itfrarrtiatlow b correct and a Plot PUP tiiowing the layout of rtetwWriot eloipmeat. For any ogatprwcat capltbk of gcwerstktg rraeh rtPurb,l hays Aldo attached a eolry of the report.(shark ap$*dr Apply)' 0 System W Up 0 Aler111 hlatery report Technician Name(print):_ �.. Signature: . Certiticittion No,- License.No,: Testing Company Name. — _ Phone No.-(----)— Site o.-(----) - --- -- Site Address:_ _ Date of Testing/Servicing: UN-etas-r/. Page I of 3 Acv,orri0,txlt w'ww w"Wocaurt