COMPLIANCE INFO 2001-2006 - Laserfiche WebLink

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' i 110 0 N fforba-,Z 'fkJP t 'QU.ALITYTES'TING OF UNDERGROUND 7ANKSATAFFORD.ABLERATES' i r 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 7,44-0116 `f Ueneral Information ;`1 Facility Name: % Bldg.No.: j Site Address: City: / ' Zip: Facility Contact Person: Contact Phone.1No.:( ) Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate geeffic equil2ment ins ected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular�9pace or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ PiFinSump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FimpSensor(s). Model: ❑ Mechanical Line Lealc Detector. Model: ❑ mcal Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑, lectronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑Y Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tye and model in Section E on Page 2). %O Other(specify equipment a 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: 4 ❑ 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: 13 Tank Overfill/High-Level Sensor. Model: El Other(s eci equipment a and model in Section Eon Page 2). ❑ 'Other(s eci a ui ment Ly2e and model in Section E on Pae 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 Chains) ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: ! Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(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 ConLtinment Float(s)and Chain(s). ❑ 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 histery report Technician Name(print): z6nlF 611 n Signature: Certification No.: License. No.: 4 672.,1,,33 2,2 (.IT Monitoring System Certification