COMPLIANCE INFO_2004-2015 - Laserfiche WebLink

Home Browse Search

Nov 18,09 10:35a 209-367-5424 p.2 QIT NG SYSTEM CETIFI TION For Use By All Jurisdictions Within the State of California Authority Cited- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A se2arate 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 ownertoperator. The ownerioperator 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: C vfj� Cr"-c�'— Gl + 0-4-& L2A-tr// Bldg. No.: Site Address: '4164 9 . /..�� ddeA 4-l-2- City: �,cs Com- Zip: 47-g-2=1_ Facility Contact Person: G.dtis 6,! - 2 Contact Phone No.: Make/Model of Monitoring System: 4L c 'Z f -Yb Date of Testing./Servicing: B. Inventory of Equipment Tested/Certified Check the a2eapdate boxes to indicatespecific equipment inspected/serviced: Tank ID: 7 Tank ID:� �&In-Tank Gauging Probe. Model: I ® In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 42 [ mnuiar Space or Vault Sensor. Model: Piping Sump ! Trench Sensor(s). Model: ,2 " Q [ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Modcl: 2, S� I [R Fill Sump Sensor(s). Model: z(S' Mechanical Lime Leak Detector. Model: tp Mechanical Line Leak Detector. Model: j..,0 ❑ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: ❑ Tank Overfill ! High -Level Sensor. Model: Q Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on Page 2). Tank]D: Tank ID: j In -Tank Gauging Probe. Model: ,t# �, _%' Q In -Tank Gauging Probe. Model: [Anular Space or Vault Sensor. Model: G -(,t ��Of Q Annular Space or Vault Sensor. Model: Piping Sump ! Trench Sensor(s). Model: � ' ❑ Piping Sump i Trench Sensor(s). Model: Fill Sump Sensor(s). Model: J -Dy ❑ Fill Sump Sensor(s). Model: rU Mechanical Lite Leak Detector. Model: _ _ &.19 DO ❑ 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: Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser 1D: Dispenser ID: (*1)ispenser Containment Sensor(s). Model: �,Zj ❑ Dispenser Containment Sensor(s). Model: Shear Valvc(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ';/;it Dispenser ID: Dispenser Containment Sensor(s). Model: .x.13 Q Dispenser Containment Sensor{s}. Model: Shear Valve(s). Q Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Q Dispenser Containment Float(s) and Cham(sj Dispenser ID:_ E& Dispenser ID: Dispenser Containment Sensor(s). Model: .2.--Qr - ❑ Dispenser Containment Sensor(s). Model: ]$ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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/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 Haat apply):. EIS- m set up ❑Alarm histo report Technician Name (print): S;c�3a � (J',�i�tC= s+ signature - Certification No.: Si! 1119--07- �, Licen N r Testing Company Name: r2Aa,6y �6a Awes /A,)jf Phone No.: (2p () Testing Company Address: �.te:L1=• 41yf t:v.11f _ `A Date of Testing/Servicing: Page 1 of 4 UN -036-114 www.unidocs.org Rev. 01!17/08