COMPLIANCE INFO 1997 - 2005 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By Al Jurisdictions U thin the nate of California Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to do cument testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. 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 Faciht�Name -- i ARCO PRODUCTS COMPANY Service StationNo.: 1.6313 Site Address: 1100 S MAIN STREET ' City:_ MANTECA Zip_ 95337 i Facility.Contact Person: ! -"S`hr� S�-, ,Q,i Contact PhoneNo.: Q o Make/Model of Monitoring System: i V k_ 7Date ofTestin /Service' CS 3S� __ - B. Inventory of Equipment Tested/Certified Check the appropriate hones to indicate specific equipment' ected/serviced: T ank ID: Tank ID: -n�-ankGauging_Probe j Model: ( �f n-TankGaugingProbe Model__ 0,.4 _ 1 .- , nnularSpace or Vault Sensor Model: HAnnularS ace or Vault Sensor ! Model: i ing Sum /Trench Sensors Model: 2U(� in Sum lTrenchSensors Model: Fill _Sensor 0: — � Model: � Model: echanical Line Leak Detector. i Model: echanicalLine Le ak D ete ctor. ! Model: yew Electronic Line Leak Detector ! Model: Electronic Line Leak Detector Model: -- - —— —- ------- T -- --- - --- - ---------- - TarikOverfillllii -level Sensor: Model: TankOverfilVHr level Sensor: ' Model ` �w --- --- gh- l S : _ l: ----- _ ---- - - - - ---- ;[]Other,Specify equip.t e and model in Section E on Page 2 bOther,Specify equip.t e and model in Section E on Page 2 Tank ID: T_ank ID: n-TankGauging Probe: j Model: In-TankGaug�-g Probe: Model: ularSpace or Vault Sensor: Model: `; -4LAnnular Space or Vault Sensor j_Model:-` ipingSump/Trench Sensor s : j Model: PipingSump/TrenchSensor(s)_� Model: Fill Sump S ens or(s): i Model: -Fi1lSump_Sensor(sZ_-- Model: Wech- 'cal Line Leak Detector. Model.~`LD1Od� ='MechanicalLine Leak_Detector. Model: e�ctrornc Line Leak Detector Model_ >.'Electronic Line Leak Detector Model: ':TankOverfilllHi level Sensor: Model: I _ _ TankOverfafHl level Sensor: Model: []Other,S e a quip.t e and model in Section E on Pa e 2 jibler,S ec a ui .t e and model in Section E on Pa e 2 Dis ser ID Z DispenserID rDisp nserContainmentSensors Model: 3 - is serContainment Sens or(s)_ Model 5- Valve s . nserContainmentFloa s and Chain(s) ElDis enserContainmentFloa s and Chain(s) Dis a serID: - Dispens erID: _ is ser Containment Sensors: ; Model: S-dt i_spenserContainmentSensor(s):_ Model: 3 S' hearValve{s). - �Z eafValve( s ElDis enserContainmentFloa s and Ch s Dispenser Containment Floas and Ch ' s DispenserID: ? v DispenserID: Z en ser Containment Sensors_ Model_ _ 3S' is ser ContainmentSensor(s): Model: 3 �- he a gr V aloes he ar V elve(s). bDisp ens erContainmentFlo a s and Chain(s)) isp ens erContainmentFlo a s and Chain(s) *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at this facility. C. C ertific ation-I certify that the equipment identified in this document was inspectedfserviced in accordance with the manufsctim s' 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 eq nt. For any equjpmnt capable of generating such reports,I hale also attached a copy of the Mort; check all that a d): __S t_e_m set- --E:TALLmhistDry rt T e clinician N ame Tint : � Signature: CertificationNo.: j LicenseNo.: Testing`Cornpan3Name: TAIT ENVIRONMENTAL SYSTEMS j_Phone No.: i (714)560-8222 Page 1 of 3 03/01