COMPLIANCE INFO_2000-2007 - Laserfiche WebLink

Home Browse Search

AUG -21-2005 11:22 FROM:UST.CO .TESTING 209-531-1796 T :4683433 P.2/5 MONITORINGSYSTEM 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 marate cern catio or re rt must be re d for each monitoring system control mei 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. Genera Facility Namt Site Address: Ig. No. Zip: Facility Contact Person: Contact Phone No.: (510 ) `) Make/Model of Monitoring System t Date of Testing/Servicing: B. Inventory of Equipment T Ce ' ed Tank ID: _._ ._.. O In -Tank u ' g M l: Annular Space or Vault Sensor_ Mode : ping sump / Trench Sensoc(s). Mode : • Zo*a ® Fill Sump Sensor(s). Model: xbanicai Linc Leak Detector Model:_ ® Elecuvnic Lim Leak Detector. Model: O Tank Overfill / High-level Sensor.Model: Cl Other (s ui trent and model m Section E on Page 2). .l. e l'n-T Gauging be. Model: O Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Modes msmm__ � O Fill Sump Sensor(s). M cal Line Leak Detector. Model: R , T , T:k1\.l U Electronic Line Leak Detector. I: O Tank Overfill / High -Level Sensor. Model: O Others ui maul type and model in Section E on Pa 2). Tamil ID: Tank ID: O In -Tank Ganging Probe. Model: U In -Tank ll Probe. Model: O Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: O Piping S / Trench Sensor(s). 1: O Piping Sump / Trench Seasor(s). Model - C1 Fill Sump Sensor(s). l: Q Fill Sunip Sensor(s). 1: 13 MwImicaldline Leak Detector. Model: Q mechanical Lane Leak Detector. Model: O Electronic Lim Leak Detector. Model: ® Electronic Line Leak Detector. Model: O Tank Overfill / M911 -Levet Sensor. Model: Cl Tank Overfill / High -Level Sensor. Model: s ui nt and model in Section E on P 2). D Other ui mene and model in Section E on P 2). Dispewer ID:peam ser Containment Sensor(s). Model: ID O Dispenser Containment Sensor(s). Model: alve(s). rDispenser O Shear Valve(s). eer Con nt Floats and (s). O Di ser Con nt Floats and Chain(s). _ -!.j/, Dispeuw ID. Containment Sensor(s). 11R • 1 O Dispenser Containt nt Sensor(s). O Shear Valve(s). O Shear Valve(s). =Chain(s). ® Dispenser Containment Flo s and s). O Dispenser Containment Float(s) and Dispm Dhqmmr ID: Containment Sensor(s). Model:q R 2. r t O Dispenser Containment Sensor(s). Model: EonDDispenser• Shear Valve(s). O Shear Valve(s). suser Containment Float(s) and Chain(s). I O Dispenser Containment Floatfs) and rhni. (.1 *lf the facility contains more tanks or dispensers, copy this forra. Include information for every tank and dispenser at the facility. C. Certification - I cardrY that the apdpmeft ideni fled;a" &CUMent was rrlced Inaccordance th the ma ' Attachedto u is o tion (e g. rs' ch ) to v • t flus information es correct and a Piot Pian showing the layout of monitorinliMpment For any eq pmeut ca ble of gen such reports, I have also attached a copy of the • (ch apply): ystem set-up to epo Technician Name (print): ..®. SigrnYauCertification No.: o• Testing Company Name,U License. N.Fi D i Phone No.:`)�� Site Address: 11, S. Date of Testing/Sery g: a/Lq ,�S ficin Page 1 of 0"1Monitoring System Ce cation