Laserfiche WebLink
MONITORING SYSTEM CERTIFICATION <br /> • For Use By All J isdsctions Within the State of California <br /> Authority Cited. Chapter 6 7,Health and Saf y Code: Chapter 16, Division 3, 77de 23, California Code of Regulations <br /> Tlus form must be used to document testing and smvicing of monitoring eqwpment. A 2gplMU cerxificatton or EgM must be <br /> UEMN* for by the technician who performs the work A copy of this form must be povided <br /> to the tank system owner/operator- r must md=A a copy of this form to the local agency rcgulatulg UST WJMM <br /> within 30 days of test date. <br /> A. Geneml Information <br /> F ' ' Name- C Service Station No.: <br /> Site Address. t ,j� 'e-- °'/ SP" City- 7 41caj Zip: / <br /> Fwility Contact Person: Contact Phone No.: —1,,P-, 3 <br /> MakeftAodel ofDate of Tice: QK <br /> B. Inventory nipment TestedlCertified <br /> iudkxbe,NE5jffC ent in <br /> Tank ID: Tank : <br /> Oda-Tankc Olo-Tank Gauging Probe. : <br /> &Anuwar Space or V O or Vardt . <br /> Sensor(s): Wiping (s). <br /> Ono SUMV sensor(s): Modek pFili Sump Sensor(s): Modek <br /> fflUh ud cal Line Leak Detector. 0 Model: banicai Line Leak DelecEor. W Model: <br /> Offlectranic Lim Leak Detector Model: Offlectrionic Line Leak Detector Model: <br /> OTauk +rel Sensor. Modek OTank vBigli . <br /> m.Sechon.E an Page 2 00ther,§pcEft SEE type and model is Section E an Page 2 <br /> Tank Ilk r Tank ID: <br /> Un-Tank _ QIn,ml r2ffc -Tank Gauging - <br /> WAumdw Spa=or V Space or V . <br /> (s): .5 OPVmg S (s): . <br /> OFM Sump Sem(s): Model: OF'IIx Sump.Sensor(s): Rte: <br /> l Dlechanikal Ian Leak Detector. h is L OMechamcal Litre Leak Dde= Model: <br /> E111lectomic Line Leak Ddector Model: 013lectrunic Line Uak Detector Model: <br /> OT M OTank Ov gh-levvel . Modek <br /> ® in Seaton E on o 2 00ther,S in section E anZ <br /> Dispenser-ID: 1 ID: <br /> Con i Co s): - �- <br /> GirShcar V s)- V s). <br /> s)and s) ODispenser Containment s)affi igs) <br /> Dispenser l®- ,3 ID-- <br /> Wispeaw <br /> CoMispensw Coma" s): Modet <br /> BUM V s). p Shear Valve(s). <br /> C s) S) ODispen=C ontsainamret pj s)and Chain(s) <br /> DispcoswID: Dispenser ID: <br /> Mispenser CD - Sensor(s): <br /> ffthm V s)- O Shear Valve(s). <br /> Containment S}and qntjLnQs Containment ant Floats)and (S) <br /> 'If the mom tanks or this form. IncIntle inflolmation for every tank and at this <br /> G CertifiNati011 - i cerifly that the equipment Identffied in this deanuent was iuspected/wrviced in mcordance withthe <br /> 'guidelinim Attached to this Certif ication is information (ems factumn' )uecemaU to ver*that this <br /> neformation is emect and a Plot Plan the layout of mmitaring equipaicut. For any equipment capablee of generating such <br /> repuM I have also attached a copy of the repoM( ag tout ),: 13tystem W rYreport <br /> Technician ): Keith Huston Si <br /> Cerlification Ido.: F'r Cyd—'C� Lim No.: <br /> Testing Companyn Precision Testes Inc Phone No.: (916)927-1557 <br /> �p a Af <br /> nzrm <br />