COMPLIANCE INFO_2002-2006 - Laserfiche WebLink

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E T Dispatch s, MONITORING SYSTEM CERTIFIC2!�TION For Use By All Jurisdictions Within the State of California ffuthority Cited.: Chapter 6.?, Health and Sgfe v Codc, Chapter 16, Division 3; Title 273, California Code ofReoulations Chis form must be used to document testing and servicing of monitoring equipment. A separate certifmcation or report must be preoared for each nonitorine system control nanel by the technician who performs the work. A copy of this form must oe provided to the tank system ownerloperator. Che owner/operator must submit a copy of this form to the local agency regulating LIST systems within 3G clays of test date. . General Information �acili "mss ,�t ty Name: � � Bldg.No.: ° 1 ` �h . Cit : ,Site Address: p' r� � acility Contact Person:— t 1 ` 4t fit'; Contact Phone No.: 0 vFake/Model of Monitoring System: /f� i S- s c Serial Number Cell Zl Z��C% )ate of Testing/Servicing:-.6/2 o/c>C. 3. Inventory of Equipment Tested/Certified :heck the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Cank ID: 771 `I/ Tank ID: 7-2 t7 /YS�s4c 3 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ] Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: a-Piping Sump/Trench Sensor(s). Model: '7 Y YS r> z M-Piping Sump/Trench Sensor(s). Model: ")f y38 C 3 D'Fill Sump Sensor(s). Model: -7e 3-Fill Sump Sensor(s). Model: 3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 3 Other(sued ,equipment pTe and model in Section E on Page 2). ❑ Other(s ecifv equipment a and model in Section E on P lank ID: 7-3 F '4- S}c v Tank H): Ty F ; 5 u(Z c ,j ] In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 3 Piping Sump/Trench Sensor(s). Model: / "3 0 -3 2 3 ®'Piping Sump/Trench Sensor(s). Model: 7 y Y 3 C 3 2 3 5-Fill Sump Sensor(s). Model. 7 5Y3(O-3 13 M-Fill Sump Sensor(s). Model: 7`f y Sq C,-3 2 3 ] Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ] Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ] Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 3 Other( ecify equipment a and model in Section E on Pa e 2). ❑ Other(specify equipment a and model in Section E on P e 2). )ispenser ID: i Dispenser ID: ] Dispenser Containment Sensor(s). Model: 7 9 t/3 80- 3 73 ❑ Dispenser Containment Sensor(s). Model: .3 2.3 ] Shear Valve(s). ❑ Shear Valve(s). 3 Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). )ispenser ID: 6 Dispenser ID: ?Z 6 3 Dispenser Containment Sensor(s). Model: 7 9 V380 3 2 3 ❑ Dispenser Containment Sensor(s). Model: F�O-32.3 3 Shear Valve(s). ❑ Shear Valve(s). ] Dispenser Containment Float(s and Chain(s). ❑ Dispenser Containment Float(s)and Chains. )ispenser ID: Dispenser ID: 3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ] Shear Valve(s). ❑ Shear Valve(s). ]Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chainsj. 'If the facility contains more tanks or dispensers,copy this form. Include information.for every tank and dispenser at the facility. �. 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.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 report;(check all that apply): ystem set-up arm history report rechnician Name(print): /n Sc: �, ,. 'r'//o Signature: i c- ,ertification No.: A 3)')/? License.No.: 302015 resting Company Name: CHARLES S E. THOMAS COMPANY Phone No.: (310 ) 323 6730 kddress: 13701 So. Alma, Gardena, California 90249 Date of Testing/Servicing: 6 /'2C' /06 Page I of 3