COMPLIANCE INFO 2004-2007 - Laserfiche WebLink

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MONITORING SYSTEM CERTIFICATION For Use 9ulhorityC'i/ed: Chapter C.7, %rdlhani5'«felyr('nrlc/C'hnp/erIIG,in Upir:,rnn3Ti/lciie �oinin 23, Cr10JI'nin Code o Reg This form must be used to document testis and servicing eduhu e ng prepared for each monitor' system control panel by the technician who tperforn�te work. A copy of this form mustrbe Provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating within 30 days of test date. b UST systems A. Generalformffatiof kz: 12 Facility Name: V7//,LN t Yy¢7 , 19 U j W y Site Address:_�yQ C�_ �`(� Bldg.No.: �� � QE_� C;ty: J�/Jc1r9�7 e� zip: Facility Contact Persou: , ' "e �,�-� , Make/Model of Monitoring System: 7'/� 3�C` Contact Phone No.:( ) S / k� Date ofTesting/Servicing: _L/a/� B. Inventory of Equipment Tested/Certified Cheek then ro rime boxes to indicates ecific a ui nest ins ected/serviced: Tank FD: ❑ In-Tank Gauging Probe. Tank ID: ❑ Annular Space or Vault sensor. Model: Q In-Tank Gauging Probe. -_-�—�' Q Annular Space or Vault Sensor. Model:---- ❑ Piping Sump/Trench Sensoria). Model: 13 Pim Sump/Trench Sensor(s). Model: ❑ Fill Sump Settsor(s). Model: �� Piping 13 Mechanical Line Leak Detector. Model:r—['' Fill Sump Sensoria). Model: 13 Electronic Line Leak Detector. Model: V El Mechanical Line Leak Detector. Model: ❑ Tank Ove ll/High-Level Sensor. Model: O Electronic Line Leak Detector. Model: ❑ Other is ecify a ui nest ty e and model inSection E o— n pn e 2 . 13 Tank Overfill/High-Level Sensor. Model:---- Tank ID: ) Other(s ecify a ui ment type and model in Section E on Pa a 2). ❑ In-Tank Gauging Probe. S,fJ El nlc ID: El Annular Space or Vault dt Sensor. Model /t tai >7 In-Tank Gauging Probe. Model: 13 Piping Sump/Trench Sensor(s). Model: Annular Space or Vault Sensor. Model: 13 Fill Sump Sensor(s). Model: F El Piping Sump/Trench Sensoria). Model: —� ❑ Mechanical Line Leak Detector. Modell ,F,K7 TJI 13 Fill Sump Sensor(s) Model:—� C3 Electronic Line Leak Detector. Model:—��-- 13 Mechanical Line Le.ak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Electronic Line Leak Detector. Model:—� C3Other(s eci a Lift nest[ e and mdel in Section E o z 13 Tank Overfill L High-Level Sensor. Model: Dispenser ID: Z- Other(s ci a ui nest t e and model in Section E on a 2). Pa ❑ Dispenser Containment Sensor{s). Model: Dispenser ID: l3 Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dis nser Containment Floats)and Chain(s). El Shear Valve(s). —� Dispenser ID: IJ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: - 13 Shear Valve(s). --- 13 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Floats)and Chain(s). LI Shear Valve(s). ❑ is nser Containment Dispenser ID: Flcat(s)and Chninfs). ❑ Dispenser ContainmentSensor(s). Model: Dispenser ID: El Shear Valve(s). L3Dispenser C�ontainment Sensor(s). Model: ❑Drs enser Containment Floats)and Chain(s). l3 Shear Valve(s). is enser ^Ifthe focility contains more tanks or dispensers,copy this font. Include inf❑om ation fbr evetry tank andnment ld stpeny�-serd t It[I>_e facility. C. Certification - 1 certify that the equipment identified in this 4ek, of w0Ki sn- V)td/service(]l�ty G/ccorJance with the manufacturers' guidelines. Plot to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information a correct cl Sand a Plot Plan showing the la ion of monitoring equipment. For any equipment capable of generating s"ell reports,I have also attach d a copy of the report;(cGeck n/!Ilrrd applt); S Technician Name(print): �et p / Alarm history report Signature: Certification No.: —� License.No.: �-Q Testing Company Name:��t�rilfl `�P s�' Site Address:_ Phone No.:( 09 t /Jl .11 k N Date of Testing/Servicing: Monitoring Page I of A- eSystem Certification 03/0I A Results of Testing/Servicing