COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

Home Browse Search

A.tUA-1110AG SYSTEM CERTIFICATION e For Use By All Arisdictions 14'ithin the State of Ca ' nin Authority Cited:Chapter 6.7, h and Safety Code; Chapter 16, Division 3, T 3, California Code of Regzrlalions 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 provided to, the tank system owner/operator. The owner/operator must submit a copy of this form to the local within 30 clays of test date. agency regulating UST systems .......: ._.A General THHfOH'llliitiOHH . Facility Name: �/C _ , e n®, A. Bldg. No.: Site Address: _ l34 ® "I /Cc? 7TL ` .•— 1J C,t> City: �o ®�> Zip: `�S`2 cto Facility Contact ,!c ; Person: .��/ Contact Phone No.: ( % Make/Model of Monitoring System: j✓ueQCA— u •--- Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ins ected/serviced: k ID: i -Tank Gauging Probe. Model: Tank ID:� ❑ In -Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: t{zcz iping Sump / Trench Sensor(s). Model: FjF .!? Annular Space or Vault Sensor. Model: o Ze) ill Sump Sensor(s).Model: Piping Sump / Trench Sensor(s). Model: 7� echanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill /High -Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other (s ecify e ui ment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: El Other (specify e ui t Tank ID: ment e and model in Section E on Pa a 2). ❑ In -Tank Gauging Probe. Model: anular Space or Vault Sensor. Model: J Tank ID: ❑ In -Tank Gauging Probe. Model: XZLPiping Sump / Trench Sensor(s). Model:_Zy s' ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: , ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify e ui ment ty a and model in Section E on Page 2). ° Model: ❑ Tank Overfill / High -bevel Sensor. Model: ❑Other Dispenser I D: P Z (s ecia a ui meat t e and model in Section E on Pa e 2). 13Dispenser Containment Sensor(s). Model: Shear Valve(sj. Dispenser ID: j ❑ Dispenser Containment § ensor(s). ModeL Dis enser Containment Float(s) and Chain(s). S,�hear Valve(s). Dispenser ID: WJiS enser Containment Float(s) and Chain(s). O Dispenser Containment Sensor(s). Model: S hear Valve(s). Dispenser ID: yZ F ❑Dispenser Containment Sens or(s). ModeL - is. enser Containment Floats) and Chain(s). �I��+Shear Valve(s). ' OI�Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser ID: X❑ 13 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ Dis enser 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 manufacturers' guidelines. Attached to this Certification is information (e.g. information is correct and a Plot Plan showing the layout of monitoring manufacturers' checklists) necessary to verify that this equipment. any equi 'lent capable of generating such reports, I have also attached a copy of the report; (check rrtt that appti.): yst rn set up larm history report Technician Name (print): AV J ';, QIP Signature: 0( it - Certification No.: f s � �2 `73 -UT License. No.:^L //�� r�%��?, Testing Company Name: 14 rTI') r bclrl 25 r Phone No.: ( ,� Gr Site Address: �3Qi I,J YL e�9� Date of Testing/Servicing: Z6/ /(ea / o b Page i- -11<'� v MonitoriBtig system Certification 1 of3 / 03/01 D. Res4L!Us (if�