COMPLIANCE INFO 1994 - 2010 - Laserfiche WebLink

Home Browse Search

MON, ORING SYSTEM CERTIFi -ATION For U.se By All Jurisdictions Within the State of California Authority Cited: Chapter 6J, Health and Safety Code; Chapter 16, Division 3, Title 23, California comicuffliv This form must be used to document 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 AUIGdld go N*k system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems .within 30 days of test dace. ENVIRONMENT HEALTH A. General Information PERMIT/SERVICES Facility Name: C j+&IZa 6(e_z�_ L-+Al2,C_ Sc dZy i c_4 Bldg. No.: Site Address: _ nt 0D S C.6FrF�2v KL`E �. 4 NLS City: Z- O 17 t C4 , Zip: 9 J 2 tE Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: e- 44t,? 1::: At C Date of Testing/Servicing:1 L r-1'2_ B. Inventory of Equipment TestediCertified Check the appropriate boxes to indicate specific eauinment lnsnectMAPrnirPri- Tank ID: Tank ID: 3 ❑ In -Tank Gauging Probe. Model: ❑ In_Taak Gauging Probe. Model: 0"Annular Space or Vault Sensor. Model: -4-0.2 s9 t t Sr Y go EYAnjiular Space or Vault Sensor. Model: P�Aa2s9 1/bS�000 2"Piping Sump / Trench Sencor(s). I Model: �,j:d02 f 2bo e000 ®'Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ek-VTechanical Line Leak Detector. Model: -57TY' —/14, n ®'lfechanical Line Leak Detector. Model: 116, —o>s(, ❑ 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 t1 and model in Section E on PaZe 2). ❑ Other (specify a ui ment ta and model in Section E on Paee 2). Tank ID: _ , PC ce S Tank ID: V D i€ SL-�Z ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: 2'�jnnular Space or Vault Sensor. Model: 44023 9 t/5-VCk=O R -Annular Space or Vault Sensor. Model: O'Piping Sump /Trench Sensor(s). Model:.dA-a �5�.200000er O'Ifiping Sump / Trench Sensor(s). Model:PrlPzS`72o oot� b ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Cil echanical Line Leak Detector. Model: Y iL —c 35 21iechanical Line Leak Detector. ::,;del: 1 / 6 - 05`9 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment Rpe and model in Section E on Page 2). ❑ Other (s eci equipment and model in Section E on Page 2). Dispenser ID: ' Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 -Shear Valve(s). ❑wear Valve(s). U Dispenser Containment Float(s) and Chain(s), r a Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ I ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Er Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ j3ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor -(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Floatfs) and Chain(s). ❑ Dispenser Containment Float(s) 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 - I certify that the equipment identified in this document was inspected/serviced in accordance with the manuracturers' 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 equitunent. For any equipment capable of generating such reports, I have also attached a copy or the report; (check all that apply): ❑ System set-up ❑ Alarm history re ort Technician Name (print): A�vj u L..ti9 Jl,�3ulZrJ Signature: /X-"- Jr ��J C Certification No.: License. No.: I�o`f 7`l 0 Testing Company Name: _ ('_,fit±Z, 4300 AltCCIS60k) 7`�N�K t�'ST w`� Phone No.: j�-Q Site Address: ICO S, (rk4EZDki li4fLAx��r L p 7� C.-4, Date of Testing/Servicing: R'Ionitoring System Certification Page 1 of 3 Coy\ IqLa�� 03/01