COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

Home Browse Search

MONITO&G/;, For Use By All Jurisdictions Within the State of California Authority 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. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form 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. Instructions are printed on the back of this page. , A. General Information Facility Name: , %" 5e�210 /Z/ S? Bldg. No.: Site Address: r�05 fit/-t/C�TO/U City: 0-r Zip: IF5 oz VO Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System:' Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 7 [Y—In-Tank Gauging Probe. Model: /741 2 l2'A-nnular Space or Vault Sensor. Model: 40 Piping Sump / Trench Sensor(s). Model: A6' ❑ Fill Sump Sensor(s). I . Model: O'fviechanical Line Leak Detector. Model: L - 0. A649 O ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Dispenser Containment Sensor(s). Model: C*]'gh_c Valve(s). C�'Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: -Tank Gauging Probe. Model: �f .2- B ranular Space or Vault Sensor. Model: 41.,77 Q,- ping Sump / Trench Sensor(s). Model: 4 0 5i ❑ Fill Sump Sensor(s). Model: 4--V O -Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -;Level Sensor. Model: ❑D' enser Containment Sensor(s). Model: Shear Valve(s). Q-15i-spenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ,� l -Tank Gauging Probe. Model: ..Flew-- .2 0 Xmiular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). • Model: d©,F- ❑ Fill Sump Sensor(s). ' . Model: C3' v�iechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s): Model: Q- ear Valve(s). ser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). . . 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 Site Plan showing the layout of monitoring equipmen or any equipment capable of generating such reports, I have also attached a copy of the (check all that apply):-OS):Stem set-up report; ❑/Aarm history report. i Technician Name (print): Aa, Cert./Lic. No.: /--;) Signature: /c 4 Testing Company Name: Phone No.: CALM -01 Pate 1 of 3 11/15/99