COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

Home Browse Search

IV LVJYVOJYJJ r lr to ri..uum MONITORING SYSTEM CERTIFICATION For Use By All✓ttritsdictions Wlthln the State of California Atrrhorky Cited: Chapter 6.7.Health and Safe$Code:Chapter 16,Division 3, Title 13. California Code of Regulations This form must be used to document testing and smicing of monitoring equiprMat.A SIRIMM urtiftutio0 Q!Ingo must be oreoared for each m„QnjWrin,g fystern control RMI by the technician who performs the work. A copy of this form must be provided to the tank: system c,wncr/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST system %%ithia 30 drys of test date. :�. Ceaeral Inform tion m FacIIity Nae: ` e.I°G1► Bldg.No.: Sitc Address: 1 2 a Ent=k od" _64-rd-s— Cir Er_-" _ Zip: g5-420Es Faciliry Contact Person: Contact Pbone No.:(,__, �'ake/?viodeII of Monitoring System: V44444,--_ vest' �� Date of Testing/Servicing: / '/OZ- B. Uventory of Equipment xested/Certifled CAetk the aro riate boxes to indicates tic a cal aunt to edherviced: Tank 1D: ° TanklD: 2-1n-Tank Gauging Probe, Model. Erla-Tank Gauging Probe. Model: 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: O Fill Sump Sensor(s). Model: O Fill Sump Satnsor(s). Model: a-Nacchanical Line Leak Detector. Modcl. Z Mechanical Litre Leak Detector. Model: D Electronic Line Leak Detector. Model: O Elerrrottie Line Leak Detector. Model: 0 Tank Overfill t Nigh-Level Sensor. Model: Cl Tank Overfill/High-Level Sensor. Model: C Other(spirciuigment tal and model in Section E on Pae 21. O Other if SguiE=nit and model in Section E on Paae 2). Tank ID: Tank 10t CD )n-Tank Gauging Probc. Model: O In-Tank Gauging Probe. Model- 0 Annuls Spocc or Vault Sensor. Model: D Annular Space or Vault Sensor. Model: C Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Modcl: O FII Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: O Mechanical Line Leak Detector. Model: p E)ccironic Line Lcak Detector. Model: O Electronic Linc Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: 0 Other(specify ui ment t e and model in Section E on Page 2). O Other( cif ui aunt type and model in Section E on Pa"2). Dispenser ID: Dispet:serID: 3 Y -3'D spcnscr Containmcnt Sensor(s). Model: O Dispenser Containmen Sensor(s). Model: ,"Shear Valvc(s). 0 Shcu Valve(s). Dis nscr Containmcnt Floats)and Chain(s). O Dispenser Containment Floats)and Chain s). Dispenser ID. C Dispenser JW. a-Dispenser Containment Sensor(s). Model: Q Dispenser Containment Scnsor(s). Model: r; •Shcar Va)ve(s). O Shear Valve(s). Q Dis nscr Containment Float(s)and Chains. O Dispenser Containment Floa s and Chain(s). Dispcnscr JD: Disputser 1Dc Z) Dispenser Containment Sensogs). Model: O Dispenser Containment Sensor(s)- Model: Q Shear Valvc(s). O Shear Valve(s). :2LIxnscr Containment Floa s and Chains. O Dis eraser Containment F125sl and Chain(s. •1 f Inc facility contains more tanks or dispensers,copy this form. Include information for everytank and dispeasetr at the facility. C. Certif icatlon ;I certify that the equipment identified In this document was Inspected/serviced In accordance with the manufacturers' gaidelines. Attached to this Certlfieattoa IS Information (e.g. manufacturers' checklists) necessary to verity that this information as correct and a Plot Plan shorting the layout of monitoring equipment. For any equipment capable of generating such reports,I have also a nach-d a copy of the r ort;(sbeoort that�f y): O System set-up lsr history report Technician m Nae(print): / �iV(1 e�Casvf Signature: r Cenifkation No.: / • D 2.- 01-11'rf License.No.: _ 1 9 Testing Company Name: Plane No.: 464-833 Sitc Address: ^I:t$te.ofTestinoetvieing: Page I of 3 03101 Monitoring System Certification