COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

Home Browse Search

11 11 ONITO G SYSTEM CERTIFICATION 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. 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. A. General Information Facility Name:,,w�a C Site Address: Bldg. No.: Q City: i Zip: I _ Facility Contact Person: ® W eY` Contact Phone No.: (qCCA ) `D Make/Model of Monitoring System: nL... Date of Testing/Servicing: I / B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: In -Tank Gauging Probe. Model: Aa In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: —�- V Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: xQA NAOSa ?t— Mechanical Line Leak Detector. Model: Le ❑ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). ❑ Other (sE22ifX Squiginent type and model in Section E on Pae 2). Tank IID: Tank : ❑ In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: '* Mechanical Line Leak Detector. Model: tom® ❑ 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 i ui ment tXE and model in Section E on Pa a 2). ❑ Other (s if Equigment t and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 'Shear Va]ve(s). E3 Shear Valve(s). r�i &LDis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 16 Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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). ❑ Dispenser Containment Float(s) and Chain(s). *If the f—ility rnntninc mnrr tanks nr dicnensers_ ennv this form. Include information for every tank and dispenser at the facility. 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 Plot Plan showing the layout of monitoring a utpment. For any equipment capable of generating such reports, I have also attached a copy of the re ort; (check all t apply): kSystem set-up ,Alarm history r ort Technician Name (print): C �� hhe Signature: Certification No.: d� l 1 License. No.: Testing Company Name: Phone NojS_� 1- G/�/b� Site Address: �O� OL ��{� Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification