Laserfiche WebLink
0 <br /> MOWORING SySTEM CERTMCATTON <br /> ,7or use By All Jurirdictions W-uhin the Sfax of California <br /> .-juritarity Cited:Clwpwr 6.7.rjealth and SafeU Code. Chapter 16,Division 3,Vrk 23,California Code of Regulations <br /> This form must be used to document testing and servicing of monitoring equipment <br /> for each M0Lqnj&naew <br /> 20WLWwl by the tCchnjc=..Vh0 performs the work. A copy of this form must be provided to the tank <br /> system ownedopemtor. The ownedopmtDr must submit a COPY Of this form to the local agency aegtthatiug UST systems tem within 30 <br /> days of test date. <br /> A. General InfOrmatiOn PACIFIC MINI MART <br /> Facility Name: _ 4511 PACT F1 C AVE N U E <br /> SiteAddress: Bldg.No.:— <br /> STOCKTON , CA 95207 Zip: <br /> Facility Contact Person: C 64 C-14'?Ma F,6 Contact Phone No.: cr�0 ILL�/�) ? <br /> Makw%odel0 <br /> (f3 C_S;a_ . Date of Te Servicing: _QyLvi,_Q_c�� <br /> of Monitoring System: <br /> B. Inventory of Equipment TftU&Cerdfied <br /> Cha&the appmpriate bum 1qb, xTN*Le <br /> 5-Tank I 11D- Q Talk 1D_ <br /> �,7T,�j�gingllrobe_ HIM-. -1 Ck I SA in-Tank Gaugn Probe Model: <br /> iff Am uW Space or V=h SaISM MGM-•_C& EI Amular Spam Of Vault SCUUM modak <br /> 0 Pipina Snap I Trench Scnsor(sX MWa El Piping SmWl Twach 5'3�3_) NIG&E <br /> Model. <br /> 0 raftsump smsox(s)- Mode, El M&unp Seusar(s). Mod <br /> 0 Mechanical U= M <br /> Lcek Dettax. GM: Ll MecbmW Lme Le*Dftcwr <br /> I . Un0L1WkD0=qW. Model-. <br /> 0 Electronic Line LcakDaccuff. Modd- a umuonic <br /> 0 Tank Overn t Mgh_Lavd Sensor. Mom: 0 TW*Overfill I ffijfrj_L,-vd Sensor VodeL <br /> 0 0am(ME&aWWMM=and model m SUMM E an Paige 2). 11 Other affz&w&!!m r_Ve and rwdel in Section E on Pa�2). <br /> n®e, <br /> -0 In-Tank Can&&Probe- Model:___jd_ <br /> Ja Ja_Tanjk Gau ?mbe. e 0 Annular Spa= aWt Sc=w. <br /> Pt Amul=Spacz or VWk Scmwr. MO&A oi-VModeLI <br /> Z2 PJPi-9 SaW I Trench SensWA)L MOM 0 piping Swnp I Trench Smsm(.%I Modek <br /> Q Fm sump sensor(s). MOW- . Fill Sump sensor(SI, Model: <br /> U Meamcal Lae Leak Detector Model: C1 M=banicd Line L=kDe==. Model: <br /> 0 accun&z Lim Leak Vm=. hiodak 0 nectanlicLane leakDerex". Mom: <br /> Q Tank Ovedn I lh&-Lzvd Sensm Modek 13 Tank OvexfiU I High-Leml Smsor- Model: <br /> 0011W(specify=_ �modedl' Section E!2�Pzw 24L�- j 0 06W imEn emam.type and nxxW in Section on Page Z. <br /> D- <br /> D i qWMxMM=T H) M S <br /> 13 Dispenser U Diq==CeartaAffnew Sense <br /> dsh�r Valv*1 ziamearyawsI. <br /> 0 Disp--Ss)and C)Wn(s:)- Q tn2AsL-d 02ain(s)_ <br /> D4euser ED- 7-F-) I FS JUt 7 -17, biwensff Ur <br /> _\S - / �s U Dkm=Containm=Seusar(s). Model- <br /> QDisperncrC-UinM== =80*). INIOW.- <br /> Shear valve(s) El Shear valva(s). <br /> a 292M Containment Float(s)and Chains}cWtairent and <br /> € D ID_ <br /> 0 Di&j�Cwui==S=-4* Model- 13 Dqxns-CommWAS Scus0r(s)- ModeL <br /> I'Sa-ShearVelve(s)- a Shear Valve(sI <br /> 22�2m coulaftaneni AQW91-and_Cb2W%1_ a Dkpem=r-butainmew Floax(%)and Chail*)- <br /> *If the facility contains Mom unb of&Spm=s.copy this farn hwb&raftm2ahon for every tank and dispenser at the facility. <br /> C_ Certilead on-1 certify am theeqapmeW Wentifted in EW.d....ftt. a amordance wr&the ' <br /> gaiddines. Attedzed to d&CertWc8dW k WOrmd"(Ag-=gW&C"Urrs,cbedcbft)amegmy to verjo Hw this Wennatim is <br /> cormet and a Plot PIM shovdag the JaYlad ef MODUSIft eq"*=NL For my equh3wat expolde of gmerating secb rqAr%I have also <br /> attacked atopy of the " apply): CI-System sa-up UrAlarm histoy el-rt <br /> _Pl4"'a' Sig=ture: <br /> Technician Name(print): (a 1, <br /> Certification No--. License-No.: 2m <br /> Testing Company Nuic: Phone Nu..(__702 <br /> Site 0�7D-&-of-Fest unser" <br /> Page I of 3 03101 <br /> Monitoring System cerfiricalfiou <br />