COMPLIANCE INFO 2001-2006 - Laserfiche WebLink

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SAF( TQAQtJ tAl / SEP - 7 2 ffvr arTeF S_ N P - 7 {� WA, A4W- )EN UNDER GROUNDTANKS'ATAI� f�J� ,,ptil� r: V T/S ' Post Office Box 36 Thornton, Ca. 95686 (209) 794,p102r 1� 794-0 E$ UeneralInformatioENVIRONMENT HEALTH r� _ PERMIT/SERVIGE� Facility Name: t�F' ! r t� P ) 5 ,1 ldg.No.: Site Address: 0 Irt r t ,b City:_ -14 ,f-00-2 e-4s Zip: Facility Contact Person: 1' r:a r Contact Phone No.: ( ) Make/Model of Monitoring System: �� >-`3 5.. (� V Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecif'ic a ui ment ins ected/ser A ed: [,E-. ank ID: ��/`t� - Tank ID13�t )1 In-Tank Gauging Probe. Model: 4/a�. O-In-Tank Gauging Probe. Model: fj1_:Y•- Annular Space or Vault Sensor,_-��lvlodel:'?:�� % :' ' -.� "?!.? 0-Annular Space or Vault Sensor.,L-/Z4odel: j� U Piping Sump/Trench Sensor(s�_7)Model: 7��{ �F�:J ,��}y" O'Piping Sump/Trench Sensor(s) -/wIodel: SCJ Fill Sump Sensor(s). 1--,3a Model: az N11 Sump Sensor(s). /�"/cModel: ❑ Mechanical Line Leak Detector. Model: 5 13-Mechanical Line Leak Detector. Model: ❑'E ti' M�t;1V1ode1: .t`- R 003— 219+ r�teF'r,. .Model: ,l -G/ ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensors Model: ❑ Other(specify equipment tye and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: r'i --e - Tank ED:.Iq ❑ In-Tank Gauging Probe. Model: tt ❑ In-Tank Gauging Probe. Model: a'Annular Space or Vault Sensor, l7Model: 7/, D Annular Space or Vault Sensor.)--fit Model: _- U'Piping Sump/Trench Sensor(s)Xz?)Model: ❑ Piping Sump/Trench Sensor(s))_-/Wodel: _7 O Er•>l Sump Sensor(s). U-Fill Sump Sensor(s). /.22Model: _ p Mechanical Line Leak Detector. Model: /a`J/1 f,-T% ❑ Mechanical Line Leak Detector. Model:� U Model:_4-3Z. !%'- ❑-Electronic-Line-L-eak•Deteetex!!'` Model: o�U W OT, ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 5 ' ' ,�..) ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: �• ?s ❑ 7 i Annular Space or Vault Sensor. Model: 2 l*nnular Space or Vault Sensor. Model:� '' 'Tr ❑ Piping Sump/Trench Sensor(s). Model: ❑-Piping Sump/Trench Sensor(s)� -ZModel: L10 i- ❑ Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). 01 Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic-Ling--eak&Deteater`,' ; 0 Tank Overfill, H gh-,.,eve.Sensor. MOuc1: ❑ Tank Overfill/High-Level Sensor. vludel: ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). Tank ID• Tank ID: ❑ 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: ❑ 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(s2ecify equipment t e and model in Section E on Pa&e 2). ❑ Other(specify e ui ment ty e and model in Section Eon Page 2). *If the facility contains more tanks or dispensers,copy 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 inforivation is correct and a Plot Plan showing the layout ofmonitoring 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 histery report Technician Name(print): /� y/`� i V/ 0 r21 Signatur:z: Certification No.: CJ/0 License.No.: Monitoring System Certification