COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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NING SYSTEM CE T IFI TI N F�'O ,e By All Jurisdictions I b'ilhin the Slate of Califo : i r Aulhorily Cite(k Chcrpler 6.7, Heallh rand S'crfely C'oc%; Chnpler 16, Division 3, Til/e 23, Califor•nicr Code of er/C�icl s L �7 This form must be used to document testing and servicing of monitoring a ui ment. A separate certifici2at prepared for each monitoring system control panel by the technician who performs the work. A copy of this forno`� 6 ;'jt ; the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency reguWing UST systems within 30 days of test date. A. General Information B Facility Name: r-C lnj(',Ma 9 1 Lt T I � Bldg.No.: Site Address: LA I City: Zip: Facility Contact Person: 11)+ CV, Contact Phone No.: (�) Make/Model of Monitoring System:611 Ll,-,-C r2—TAA( Date of Testing/Servicing: 04 /30/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: Tank ID: 91 UlIn-Tank Gauging Probe. Model: 2 Vin-Tank Gauging Probe. Model: 2_ -E�,Annular Space or Vault Sensor. Model: 1A Z0 V anular Space or Vault Sensor. Model: t( 0 Piping Sump/Trench Sensor(s). Model: .Z O ' iping Sump/Trench Sensor(s). Model: LJ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model j= era•g t, 4YMechanical Line Leak Detector. Model:-t.9 2-000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank-Overfill/High-Level Sensor. Model: ❑ Other(s cify equi ment type and model in Section E on PaLe 2). ❑ Other(specify equipment ty a and model in Section E on Pa e 2). Ta k ID: f Tank ID: n-Tank Gauging Probe. Model: t`�11R ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 2 0 ❑ Piping Sump/Trench Sensor(s). Model: IFill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LID 2.Oac> ❑ 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(s ecif a ui ment ty a and model in Section E on PaLe 2). ❑ Other(s eci a ui ment type and model in Section E on Pa&e 2). Dispenser 1D: ; Dispenser ID: 4 Dispenser Containment Sensor(s). Model: Zb ispenser Containment Sensor(s). Model: 2 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). D' penser ID: 5 � De penser ID: t Dispenser Containment Sensor(s). Model: 2CO Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis eesser Containment Floats)and Chain(s). "If the facility contains more tanks or dispensers,copy this form. Include infbrmati n for e ery tank and dispenser at the facility. C. t srt 1*- 4 Certification - 1 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,l have also attached a copy of the report;(check all Kral apply): ❑Syst m s u ❑ Alarm history report Technician Name(print): Ludes N I ry, Signature: Certification No.: 0 License.No.:� Testing Company Name: :ozq> t5l, Phone No,:( 7— r7 Lf'-j 01 1 Z- Site Address: (� Z-,,j -,+- Date of Testing/Servicing: Q /5 /61,7 _ � Monitoring System Certification Page 1 of 03/01 D. Results of Testing/Servicing