COMPLIANCE INFO_2007-2011 - Laserfiche WebLink

Home Browse Search

`06-28-110 14:12 FROM-gest Star Envmt Inc. +559-277-0106 T-708 P0003/0007 F-325 MONARING SYSTEM CE TIS !TIO For Use By All Jurisdictions Within the State of Cali ornia Authority Cite& Chapter 6 7, Health and Safety Code; Chapter 16,Division 3, Tat e 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A e state ertification o art must be re e for each monitoxing system control panel by the technician who performs the work.A copy of this forth 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: � Bldg,No.: Site Address: City: Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Servicing: / / B.Inventory of Xquipmt nt Tested/Certified Check the upgrapriate bose9 to indieate specific equipment inspected/serviced., Tank 110- Tankw- 13 Gan Drabs. Model:_ ❑In-Tank Gauging Probe.- Model: 13 � ❑Annular.Space or Vault Sensor. Model. ❑Annular Space or Vault Sensor. Model: _ ❑Piping Sump/Trench Sensor(s). - Model: ❑Piping Sunup/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: _ ❑Mechanical Line Leak Detector. Model: _ __ ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: __._ ❑Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor.Model: [3 Tank Overfill/High-Level Sensor.Model: ®Other LsLeci&Souipment a and model in Section B on Ego D. ❑Other(M2iQ e i ment Inc and model in Section E on Page 2). Tank ID_ Tank I<D: ®In-Tank Gauging Probe. Model: _ in-Took Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Pi iIIg Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fi l Sump Sensor(s). Model: 0 Flu Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Electronic line Leak Detector. Model: Tank Overfill/High-Level Sensor,Model: Tank Over-fill/High-Level Sensor.Model: other s eci ui ment a and model in Section E on Pae 2. Bther 2 s ec*a ui ment a and model I Section E on Pa a 2). Dispenser li?- — Dispenser JD; Dispenser Containment Sensor(s).Model: 13 Dispenser Containment Sensor(A).Model: Shear VaIYP(S). Shear Valve(s). LS um COn lnnl 08 a 'an am S . Dispenser Containment o San S . Dispenser ID- Dispenser 1D- Dispenser Containment Smsor(s).Model: Dispenser Containment Sensor(s).Model: } Shear Valve(s). Shear Valve(s. Dia enser Con 'inlS an Dis eraser nntainmen o s an n s . ispenser W- ❑ Dispenser Containment Sensor(s).Model: Dispenser Containment Sensor(s).Model: 0 Dispenser 1D- Shear valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). dispenser Containment Float(s)and Chain(s)..... •if the facility contains more teaks or dispensers,copy this form,Include information for every tank and dispenser at the'facSlity- C. Certification-Y certify that the equipment identified in this document was inspected/serviced in accordance with the mfacturers, guidelioes.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 report;(check all that apply): ❑ System Set-up ❑ Alarm history report Technician Name(print): Nick Adarnitz Sigsaature: .(D . Certification No.:- LCO2 License.No.: 505142 Testing Company Name: West Star Environmental phone Number: (559)277-9378 Site Address,, 4688 W Jennlfer, Suite 101 1 Fresno CA 93722 nate of Testing/Servicing: Page i of 4 03101 Monitoring System Certification