COMPLIANCE INFO 2001-2006 - Laserfiche WebLink

Home Browse Search

�a �x rjp 'QU,4LITYTESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' 7 . Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 Ueneral Informatio�l Facility Name: f /ft"� �Pl-s t°/� Bldg.No.: nn � Site Address: 5/V Gt'(? /'i > iJ( City: Zip: Facility Contact Person: AWla Contact Phone No.: Make/Model of Monitoring System: /° N'( Date of Testing/Servicing: �7 Co/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: M Oe 01 ❑ In-Tank Gauging Probe. Model: YI Far q ❑ Annular Space or Vault Sensor. Model: �36 —PL() ❑ Annular Space or Vault Sensor. Model: —Zy=o ❑ Piping Sump/Trench Sensor(s). Model:7111Af ❑ Piping Sump/Trench Sensor(s). Model: ?t?,/3e-0 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: — ❑ Mecharlical 1'ne Leak Detector. Model:A/(' P*2 L7 ❑ Me ianica Dine Leak Detector. Model: C/// ❑ M?'✓��l r '' Model: y S3' ❑ El cdsi' ' e�tectcu. Model: "a+C�� ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: 3 Tank ID:R &14 4- 4 IJ ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 4110 ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model:70t!yto— .Z0 C ❑ Piping Sump/Trench Sensor(s). Model1 Q ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ;;?C) 7.710 ❑ Me ante Line I/eak. etector. Model: '57R m.0tt7 ❑ Mec rani a Lioae Leak Det ctor. Model: Ele✓ i,% —tecxer. Model: $ tectrai� - e�Ctes. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specifv equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser 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). ❑ Dispenser 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). I ❑ Dispenser Containment Float(s)and Chain(s). *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 information 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 history report Technician Name(print): Certification No.: 6 License.No.: J U L 2 8 2004 ENP RMIT/SERVICES HEALTHRONENT Page 1 of 3 ATG Monitor Form Monitoring Svstem Certification