COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

Home Browse Search

TRACY TRUCK STOP 209 832 SS07 04/08/04 01:09pm P. 003 MONITORING SYSTEM CERTIFICATION UL For Use BV All Jurisdictions Within the State of Cal forma Authority Cited; Chapter 6.7., FMealth yawl SajiAt-y Code: Chapter 16, Division 3, Title 23, California Code of Reguli do t This form most he used to document testing and servicing of monitoring equipment. A separate certification or re„ltart must be pren"ed for each monitoring system control none] by the technician who perforans 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:71041 C (_ Bldg. No.: Site Address: `� ` l' ,-L T7La c V _ ii .Lv � City: ��ic..� _�; a_._____ Zs p: Facility Contact Person: __. �. Contact Phone No.: (--- ) Make/Madel of Monitoring System: L (• t L'o.< Date of Testing/Servicing: B. Inventory of Equipment este Ce "€ted Cher3t thea mate boxes to lndieate s flc equipnMit ins ectediaervica Tank TD: ! -73'7_ I-In>Tank Clanging Probe. Madel: �fA ' -. IrAnnular Space or Vault Sensor. Model: l�%_ 4C- �Z- cr. — 2liping Sump / Trench Sensor(s). Model: 13 pill Sump Sensor(s). Model _-_----- W'iMechanical Line Leak Detector_ Model: Q Electronic Line Leak Detector, Model: 13 Tank Overfill. i Hugh -Level Sensor- Model: ® Other (specify eciWipment type and model in Section E on Pae 2). • In -Tank Ganging Probe. Model: , n� t Q i � ("Annular Space or Vault Sensor. Model: ��4, i k �.,_s / 9"Piping Sump /Trench Sensor(s). Model: F4 nZ79,zoc cr.) C3 Fill Sump Sensor(s). Model:--- 21"Mechanicai Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: —~ (3 Others i uipmenL!ype and model in Section E on Page 2). Dispenser 1411) i - 2 U �ilispenser Coutainment Sensor(s). Model:—---_ ar Valve(s). Iff Dispenser Containment Float(s) and Chain(s). Dispenser in: ate_ ❑ Dispenser Containment Sensor(s). Model: 0 -shear Valve(s). 0 'Nispenser Containment Float s) and Chain s). Dispenser ill. ® Dispenser Containment Sensor(s). Model S ]S'i] Valve(s). tspenserContainment Ploat(s) and Chain(s). Tank 1D: "5 L a= In -Tank Clanging probe. L -Annular Space or Vault Sensor. piping Sump / Trench Sensor(s). O Fill Sump Sensor(s), mechanical Line Leak Detector. E3 Electronic Line Leak Detector. Q Tank Overfill f High -Level Sensor. ® Other (sneecifv enuinment tune send Model: re -- Model: 41190 a5Y 114 d© Model: !J% >S�eoaF� t 4141 Model: Model: _ Model: P4 -.w Model: ►oriel in Section E on Page 2)- TankID- t C: 5i�:L C_s' Wln-Tank Garaging probe. Model: f - QrIGnu)ar Space or Vault Sensor. Model: ,¢ro';kS41 t r'i 1 C"o rdrf'iping Sump /Trench Sensor(s). Model: P ac <x t to ® Pill Sump Sensor(s). Model: echanical Line Leak Detector. Model rF r Fi oc a 13 Electronic Line Leak Detector, Model: C] Tank Overfill / High -Level Sensor. Model: U Otter s -i er{uipn=t type and model in Section E on Page 21. Dispenser ID: - _ Ll Dispenser Containment Sensor(sj. Model: EF Valve(s). Dispenser 1D• _ 1 t L7 Dispenser Containment Sensor(s). ER-Sfiear Valve(s), 3" -Dispenser Containment Float(s) and Dis - ID: ® Dispenser Containment Sensor(s)- 0 Shear Valve(s). Model: Model: 0If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Celr:tification - i eertify that the equipment identified in this deeament arias inspeeted/servieed is aaet'sr4ktnee with the ruaniefaetturers' guidelines. Attached to this Certification is information (e.g. utanafacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such repots i have also attached a copy of the report; (check all that apply): U Systettt set-up Inhistory re rt (/ Technician Name (print):_ .1`1Lv r ti' ( , `'l !L Signature: Certification No.: License. No.: �'� "C3 C C' Testing Company Name: C GdYLis'%tr s�i1::t5/a� it luk 7-t'.5'1itti PhoneNo.:( Address: i`61 T (� Date of Isatin Servicing: Page 1 of a ostoa Monitoring System Certification