COMPLIANCE INFO_1998-2003 - Laserfiche WebLink

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MONIT01UNG SYSTEM CSR (: ON . _For I!u ByAlllurzsdiczions Within theSrase of California Authori yCaed•C&V9er6.7.Xealih andSofWyCod,:ChaprerM.Diwswn3,Tstle 23.Califvr=Code of RguWw,, This form must be used to docameat testing and savick g of monitoring equipmeat.A separate certification or Mgrt must be pMoarrd for each monitoring system con6ml panel by tie tacluucian who performs the wO& A copy of this form must be provided to the tank system ownufoperatm The owuedopaator must submit a copy of this form to the local agency m9ulating LIST SYSCCUIS within 30 days of test date, A. General informatie FacilityHamer Bldg.Noy lt�l� _ -- SitcAddrtss: City. _ -- zip: Facility Contact Person: J<Ab ► Contact Phone No--( ZOR Makc/Modd of Monitoring S .tr��?tS-3''S_(7 Date of TestiagJServidng: (-7 /� B. Inventory of Equipment TesteWelrtified J J cheekttte - Ems to k Tank ID: TankID: y0�yIu-Tank CaugmgProbe. Model: f`*" IAS Model: In-Tank AaaularSpa _-ocVatcltSeasoc Model: AnnularSpaoeorVaultSaasor: Model NOT Piping SumpITrra&Sensoc(s). Mold: .O Piping Sump/TreadiSesor(s). Model 2tS1� EM SUOV � odet Mo LmeLeakDamtoc Model:_ C.h;}ZOLO ® M h(od=tcdL=1jwkDaoaor- Model: eAZcz�� 0 E1cWv L=cLeakDetoctoc Model: t EtoacomcLme1"kDetoaoc Model: ATankOvcM11Ugb4 Mel S== Medd: c Xttoy J?lTank Overfill/Ifigi9xvelSensor. Model: 0 Othcr( �ttypcxndOther( model in Soaim Ear 2). ®Odaer( and model in Section E on Page 2). rTank ID• TankID: t La-Tank obe.ank Gauging PrModel 0 in-Tank Garaging PrOe. Model: �f AnnularSpaccorVatiltScasor. Model: 0 AnnularSpaaorVwltSensa: Modd: Piping Sump/Tr=ench Scasor(s). Model 0 Piping Sump/Trench Scasot(s). Model- 0 Fla Sump Scasor(s). Model: Q fill Sump Seasor(s). Model: *Mechanical Line Leak Detector. Model: 2cGJ 0 Mechanical Lino Leak Daxwc Model: 0 E ctronk Line Leak Detector. Model: 0 Elcouvaie Linc Leak Detector. Modd: 1t Tank Overfill I l4igh4,evo1 Sensor. ModeL-4if/1 I rX_ 0 Tank Overfill/lfiglaxM Sensor_ Mod& 0 Other(s equipment and model in Soaion,E ort Pa a 2). 0 Other( ui t and model in Sectiori E on Pa a 2). Dispenser ID:_ 'bZ/ Dispenser ID: 0 DispcnscrConta Went Scasoc(s). Model: 0 DispcnserContainment Sedsor(s)_ Model: Shear Valve(s). Shear Valv,*). D Containment Float(s)and ChaWs). Di m Containent Float(s)and Chain(s). Dispenset ID.- >!{ Dispeaser.ID: 0 Dispenses Contaimuett Seasor(s). Model: 0 D' ContainmentS«tsor(s)_ Model: Shear valvc(s). 0 shear Dispertser Containment Float(s)and Chain(s). Cl DmpeaserContainuicat Float(s)and Chain(s). Dispenser ID:—__'597 Dispenser ID: 0 D"rspensaGontainntattSatsor(s). ModeL- Cl DispertserContainmrn(Seasor(s). Model: Shear Valve(s). 0 Shear Valve(s)_ Di Containnxnt Flog(s)and Chain(s). 0 Di Containment Float(s)and Chain(s). *If the facility contains more tanks or dispenses,copy this form Include information forevery tank and dispenser at the facility. C- CertifiCation-I certify that the equipment identified in this document was insptctedlserviced in accordance with the manufacturers, 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 equipment_ For any equipment capable of generating such reports.,I have also attached a copy of the r rt;(ch fall th ply): System set-up history report Name Technician Nae(print): Signature: c //�� Certification No.:_3(�v� License_hb_: OC�"(�re Testing Company Name:T aCLN e F nU tt-or1n1L rti �r�, Phone No.:(&l , � ) 7 -7 U a L7 -.- - Site Address:25 2 41 �a �� ,�C ®u cl yr��ok c!s 9tSo� Date of TestingfServicina:�� I�� ..f 3 \Iauitir+n<<rtitii:niun