COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

Home Browse Search

r L in rLVVrc r'HIaL U4 MONAORING SYSTEM CERTIFI TION ` For Use By All Jurisdictions Within the State of California Aurhority 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 separate certification or report must be prepare for each monitoring system control taansl by the technician who performs the work. A copy of this form must be provided to the tarty: system c,%vner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 djys of test date. A. GeneralInformation Facility Name. TGI'Gk-`rBldg.No.: Site Address: Ctly: er w►� G'�,•.� _ Zip: �JSa106 Facility Contact Person: Contact Phone No.: vlake,Nodel of Monitoring System: V 41--e jgj?y E TL.S &IL Date of Testing/Servicina.- O? B, Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecirac a u)ement Ina eeted/xn'icod: Tank 1D: ' Tani:ID: 0-In-Tank Gauging Probe. Model: El-In-Tank Gauging Probe. Model: 2-"Annular Space or Vault Sensor, Model: 2-Annular Space or Vault Sensor. Model: (a-'Piping Sump/Trench Sensor(s). Model: .0-Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: 2-Mech3nical Line Leak Detector. Model: .Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector, Model: O Electronic Linc Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: O Other(s ecif ui ment t e and model in Section E on Pa2. O Others cif c ui ment t and model in Section E on Pact 2). Tani,ID: Tank ID: 0 !n-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. model! ❑ Piping Sump r Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s) Modcl: t ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Lcak Detector. Model O Electronic Linc Leak Detector. Model: Q Tank ON erf,ll I High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: 0 Other(specify ui ment type and model in Section E on Page 2). O Other(s ecif a ui ment typS and model in Section E on Pa^e Z). Dispenser ID: 2. Dispenser ID: 3 -®'"Dispenscr Containmcnt Sensor(s). Model: O Dispenser Containmen Sensor(s). Model: LTJ-Shear Valvc(s). O Shear Valve(s). 0 Dis =ser Containmcnt Floats)and Chains ._ O Dis enser Containment Float(s)and Chain(s). Dispenser ID. E- Dispenser ID: O"Dispenser Containmcnt Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model .0-Shear V21ve(s). ❑ Shear Valve(s). 0 Di5pcnscr Containment Float(s)and Chain(s). ❑ Dispenser Containment Floatisl and Chain(s) Dispenser 1D: Dispenser 1D: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). D Shear Valve(s). ODispcnscr Containment Float s)and Chain(s), ❑ Dispenser Containment Float(s)and Chains. ,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 r on;(ch kart that a ty): Q System set-up B-Alsrr�history report Technician Name(print): �AJ /e'Gis,.t�r Signatuet: Certification No.. I5__7 — License.No.: Testing Company Name: • Fhone No.:( ?Q9 ) 464-82K ______ Site Address: ..Date of Testing/Servieing: Page I of 3 Monitoring System Certification F� a a