COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

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Authority Cited: Chapter 6.7, A and Safety Cade, Chapter 16, .Division 3, 43, G'alijornta t oete of xeguranons ;`/'his forst must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pmared 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 agency regulating UST systems within 30 days of test date. A. Generallnformati�5 Facility Name: `C' L/ �� Bldg. No. Site Address:_e 3 l S City: _ Zip' Facility Contact Person: Contact Phone No.: L� Make/Modell of Monitoring System: A -c%,_-' Date of Testing/Servicing: B. Inventory 'of Equipment TateWCertified �Jn e ro date boxes to Indicate wife equipment hupectedtsen iced: _ aT77 : nk Gauging Probe: Model: M. e� — _ Tank Gauging Probe. Model: alar Space or Vault Sensor. Model: ° �=P* alar Space or Vault Sensor. Model 'p Sump / Trench Sensor(s). Model: ng Sump ! Trench Sensor(s). Model: /,� Of'11 Sump Sensor(s). Model: ill Sump Sensor(s). Model: ?_ Rf Mechanical Line Leak Detector. Model: ' t � Mechanical Line Leak Detector. Model: 13 Electronic Line Leak -Detector. Model: O Electronic Line Leak Detector. Model: ( &ffank Overfill / Hi Model- ci ;1 tv6IS 6 L& U_ Tom_ Overfill . Model: d^—/—, D Other ( ify equipment and model in Section E on Page 2). U Other ( iij► equipment type and model in Section E on Page 2). Tank ID: Tank 10D. - 0 :O In Tank Gauging Probe- Model: O In Tank Gauging Probe. Model: 'S O Annular Space or Vault Sensor. Model- O Annular Space or Vault Sensor. Model - 0 Piping Sump / Trench Sensor(s). Model: O Piping Sump / Trench Sensor(s). Model: r O Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. - Model: O Mechanical Line Leak Detector. Model: i. O Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: O Tank Ovefill / High -Level Model: O Tank Overfill / High -Level Sensor. Model: #O Other (specify equipment type model in Section E on 2). O Other (specify equipment model in Section B on Page 2). I?ispenser DID: 11 O D- Containment Sensors). Model: Containment ensor(s). Model: 3 Valve(s). Valve(s). Dispenses Containment Floats) and Chain(s). Containment Floats) and Chain(s). r Dispenser ID: Dispenser ID: O Dispenser Contact Sensor(s)_ Model- O Dispenser Containment Sensor(s� Model: O Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floats) and Chain(s). O Dispenser Containment Ffoats) and Chain(s). :+ ..Dispenser ID: Dispenser ID: O Dispenser Containment Sensors). Model• 0 Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). ti ODispenser Contaimnent Float(s) and C sm(s). O Dispenser 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/servieed In accordance with the manufacturers' guidelines. Attached to this Certification Is Information (eg maaufa rers' checklists) to verify that this information is correct and a Plot Plan showing the layout of monitoring p For any equip t capable of generating such reports, I have also attached a copy of the report; (check aII that apply • t -up Alarm history report Technician Name (print): Tom Corcoran Signature: �� -�. Certification No.: 00-7S31 License. No.: Testing Company Name: Triangle Environmental, Inc. Phone No.:(818)840 7020 . Site Address: Date of Testing/Servicing: Page I of 3 03/01