HomeMy WebLinkAbout2013 RESULTS A FORMMONITORING SYSTEM CERTIFICATION
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For Use ey All Jurtrdtetionr Within the State of California
Authority Cited: Chapter 6.7, Health andSafery Code; Chapter 16, Dtviston 3, TO a 23, CalffMia Code ofRegulmfom
This form must be used to document resting and servicing of monitoring equipment A senamill: cartificigioll Or Noun mild be claimed for each
monitoring sr_`al control Dnr -I by the technician who performs the work A copy of this form most be provided to the calk system owna/operamr.
The ownenopammr must submit a copy of this than m the local agency regulating UST systems within 30 days of test date.
A. General Information
Facility Name: ORANGE BELT STAGES Bldg. No.:
Site Address: 3640 SILLECT AVE City: BAKERSFlELD Zip: 93308
Facility Contua Person: MATT ConMCt Phone NO.: ( )
Make/Model of Monitoring System: Date of Temidg/Ssevicing: 6129£2012
B. Inventory of Equipment Tested /Certified
Check me appropriate boon to indicate specific racilmsent remurvweo:
Tank ID: DIESEL
Teak m:
®In -Tank Gauging Peak Model: MAGI
® anula Spar or Vaud Seno, Model: TRANSDUCER
®Piping Sump/ Trench Senmr(s), Mode: 208
❑ Fill Somp SeaSIX(s). Model:
® Mechanical Line Leak De elor. Model: FX1DV
❑ Electronic Line Leek Dalecmr. Model:
❑Took Ovcefill /High -Level Scrum. Model:
❑ od. (specify equipment type and model in Section E on Page 2).
❑In-Tank Gauging Robe. Model:
❑ Armuler Spent or Veet Sensor. Mode:
❑ Frying SemD l Tmnuh Streets). Medal:
❑ Fin Sump Scamus). Model:
❑ Mechanical Lim Leak Delusion. Modal:
❑ Fle000nk Line Leak Dnemor. Model:
[3 Tack Overall /High -l-cid Scmm. Modal:
❑ Ones, (specify equipment type and model in Section E On Page 2).
Tank ID:
Task m:
❑ WT ad Gwgina Rohe. Model:
❑ Male Spa"Ou Vent somr. Modal:
❑Apinsomp /TrermhS ..W. Model:
❑ Fill Somp Senon't Model:
❑ Mechanical Line trek Drente. Model:
❑ Meetings k 0c Drn ink Detects. Model:
Tank Overfill /Ri -love Sanor. Model:
❑ Res'
❑Omer(spsify equipment type and made in Section East Page 2)
❑m -Took Coging Probe Model:
❑Aooulm Spaces m Vauh Stage. Model:
[3 piping Sumo/ Treach Sector(s). Model:
❑ Fall Sump Sunni Model;
❑ Meemntid Lim Lek palate. Model:
❑ Elecnonk Line Leek Deter as Mode:
❑06 Distill l High-Less] type and Model:
❑Other(sPecify equipment type end model in Section Em Page 2).
Dispenser ID: 1
®Dispcmer COntalnmmn Smor(s). Model: M4TAND ALONE
® $Mar Vow,),
❑ Dispenses Containment Fluet)and Chablis).
Dispenser m:
❑Disperser COntai— Semer(Q. Model:
❑ Shrar vel tot
❑Defter. COntin Flom(i) it Chasms).
Dispenser m:
❑Dkpeme COnnimrran Sensm(s). Model:
Dispenser m:
❑Dispmam CoNsimentSessids). Model:
❑ Shev Vevas).
❑DmM. Containment SOINS) and Chnin(s).
❑ Shea Valves).
❑D'spooser Comainmed, Floags)and Chains).
Dispenser ID:
❑Dsperseu Contafmnerc Seemns). Modi
Dispenser m:
❑DispvuerConlemnont Smgcas). Modal:
❑ Shear Valva(s).
❑ Dispenser C tsumu ROW(s) and (2huin(s).
❑ Shest Valve(6).
❑D'uper. Containment Floags) sedChain(s).
—inisf Incl.dales£osmeionforeve
Mkanddispcnseratne facility.
C. Certification - I certify that the equip -eat Identified In this document wet inspected/serviced to accordance with the manufacturers'
guidelines. Attached m this Certification is information (erg, manufacturers' checklists) necessary to verify that this information is
correct and a Plot Plan showing the layout of Noonan ng a uipmevt. For any equipment capable of generating such reports, I have also
aeaehed a copy of the report; (check all that apply): System set -up ® Alarm history report
Technician Name (print): JAMESRICH Signature:
Certification No.: A2963611064166 -UT License. No.: C611 D40 809860
Testing CanpanyName: RICH ENVIRONMENTAL Phone No .:(661)392.8687
Testing Company Address: 9643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testin£/Servicing: 611912013
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