COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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ONITO G SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calyornia Authority Cited:Chapter 6.7,Health and Safety Cade;Chapter 16,Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A segaarate certificatiofi or report must be prepared for each gmtoring 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. General Information Facility Name: S 0 3 Bldg.No. Site Address:�1-ffrn Ho City: �__CQGa1 Zip: Facility Contact Person: f" Contact Phone No.: 1 4 R' Make/Model of Monitoring System: Q Date of Testing/Servicing: B. Inventory of Equipment Tested/Cerdriied Check the np=priste bores to Indicates itk a ut meat Ire$ ed$"Ced: Tank ID: Tank ID. In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ �0 O Annular Space or Vault Seng. Model: tW Piping Sump/Trench Sensor(s). Model: 'j4�,3fitj'.10 _ ❑ Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model:_ O Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: N dye — O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: \t¢,ul�e� O Tank Overfill/High-Level Sensor. Model: ❑Other OEEifX equipment type and mo4cl in Section E on Page 21 O Other(s i ui ment=and model in Section E on Pae D. Tank ID: t Tank ID: ee n-Tank Gauging Probe. Model: 0 AAco O In-Tank Gauging Probe. Model: _ Annular Space or Vault Sensor. Model: 1 ❑Annular Space or Vault Sensor. Model: _ Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor($). Model: O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: _ jYTank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: .i ❑ Other(sp!!Fify equiEment and model in Section E on Page 2). O Other(specify equipment type and model in Section E on Pa a 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). Dis nserContainmen Flo! s and Chains. O Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ,QrDisF2nser Containment Floa s and Chains. O Dispenser Containment Floa s and Chains . Dispenser ID: 2 t Dispenser ID:. O Dispenser Containment Sensot(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). Dis nser Containment Flo! s and Chains. ❑Di nser Containment Flo! 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.go manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equiRpent For any equipluellt capable o generating su rep rts,I have also attached a copy of the report;(check all that apply): ystem set-up Alarm history eport Technician Name(print): Gregg R. Geltz Sigrtatur , Certification No.: 5250561—UT License.No.: 491948 Testing Company Name: Central Petroleum Mdintenance Phone No.:(9 2 5 ) 462-4060 Site Address: Corr. ffiPoLde, - Date of Testing/Servicing: UN-036-1/4 Page I of 3 Rev.06/04/01