COMPLIANCE INFO_2003-2012 - Laserfiche WebLink

Home Browse Search

Jul LIS 10 11:05a Elite IV Contactors 12094616342 p.2 C1 MD -N WS I '1W-N--S2-0'S FWACT, kTM— 1 1- Azdhoriry Cited. Chapter 6-7, Health and Sajtry Code. Chapter 16. Division J. Tide 23. Caqornta Code of'Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system comol panel is installed at the facility, a senarate certi - ' -It must kac2amd for each monitoritlst syrmonitor' LQ=mUa_ncj by the technician who performs th& work. A copy of this form must be provided to the tank sMem 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. Instructions are printed on the back of this page. A. General Information Facility Name: kI L t i V-Oc'l Bldg. No.: S-.!-- Addrm:— city- -&A-ky, oz ZiP7 Facility Comct Perim: — XIn-TraskG"09 Ptobc. Contwt Phone No.: (—) or Vault Senior. Make/Model of Monitoring System. F' rand+Scomr(s), Model: 2 Ot Date of Testiug/Semciog- /iF 6q. 13 Mechanical Line Leak Detector. Model: B. Inventory of Equipment Tested/Certiijed Tank W. 19-7 — XIn-TraskG"09 Ptobc. Model: i or Vault Senior. Model: F' rand+Scomr(s), Model: 2 Ot fat'Fill SumFS--"(4 model: 7--a-Ge 13 Mechanical Line Leak Detector. Model: O.Elecmxhc Line Le* Detector. Madel- 4W f cf- 13 Tank Owmill I fth-l-evel Sewer. Modd: arsnit serwqx). Mom, ay 3?r Q shear valve($). 13 DLTcwcr Contaiantent jqoaqs) and s). 0 O"W (%Pccift PEU'Pineftt Type and made] in setion 6 on P14Sc Tank 13D: 0 hi -Tank Gauging Probe. — Model. 14AF 0 Annular Spam or Vault Sensor. Model: '13 Piping. samptTre-h Sc-uq$X Model: E3 fill Sump Sermor(s). Model: 5 6 0 Medwical Line Leak Detector. Modd: El Elec"ate Line Lasit Oftector. MWd- Q Tank Overfill / Hisit-Level Sensor- Modd: 0 Diqmmr ConlGininent S"Wor(s). Model: -LO Cl Show Valve(s), 13 Dispenser Cknuanuncot FWs) and Chant(s). 0 Other ($Rtxifp eq!#Pwat type and 8mdcl in Section E on Pare 21 Task a) (3 Annalor Space or Vault Sensor. Model - E) Piping SurnpiTmach Scosor(s). Model: vlq% 12 Fills Sensor(s). - 0 Mechanical Line Leak Detector. Model. Q Rectrosic Line Leak Detector. Model: 13 Tank Ov"dt I high -Level Sewer, Model: Q Dispenser Containswiv sensor% Model: a smar VAIVC(N). a Dispewer Containmentnoax(s) and Cham(s), 0 Other (specify couituric., tvac and model in Section F an P-ar. "I Task 11): U Is -Tank Ganging Probe Model: Q Annular Space or Vault Sensor. Moft]: 0 Piping Sat qVTr=ch Sensor(s). Model: Q Fill Surnp Sensor(s). Model; 0 Mechanical Line Leak Detector. Model: 13 Electronic I -me Ualc Detector. MOM: CI Tank owrrat I High-Uvel Sensor. Model - 0 Dispenser ContahanentSensor(s) Model: C) Shcar valye(st (3 I)ispcnm Can Floaqs) and ChWs). 0 Odw (speci!X equi2acat = and tnodcl in Scction E an Page 2). C. CCrtWe*0OU - I ft"IfY that The equipment identified In ft document was Inspected/serviettl in acrordsacc vrith The manufacturers' guldellues. Attached to this Certification is information (cg- wasufacturers' cbeeklists) rActsiary to verify that This informdon is cot rftc and a Site Plan sho-i"t The layout of monitoring equipment. For any equipment ca"b'e Of gemmdsg 5-13 -Por'34 I have also attached a copy of the (check all that qppfyt: 13 System set-up report; C1 A18M histery rqm-L Technician N (print) i:> d Testing Company Now. z 1, it/ Phone NO.: