COMPLIANCE INFO 1999-2007 - Laserfiche WebLink

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t n1 14 u 7ER ;'QUALI7YTEST/NGOrUNDERGROUND7ANKSATAFFORDABLE�PE Post Ofce Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 General In ormation T Facility Name: A 4-- UCYr �, �!L' (� Bldg.No.: Site Address: !i� �0 .fi/may i"I uta N City:� Q,/L /7 j Zip: Facility Contact Person: )i Contact Phone No.: Make/Model of Monitoring System: 1XQ, 7-�- S 3Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicate specific a ui ment ins ected/serviced: Tank ID: W 2.5 T .1 'er jffi 7:t7Tank ID:_ r a n t P t^-- 7-tN f! .ti r•/ " �+J :c- ❑ In-Tank Gauging Probe. Model: /17 jW"�t. / O'fn-Tank Gauging Probe. Model: 07 de O Annular Space or Vault Sensor. Model: ?'IfJ3 9 HH7{} O-lZnnular Space or Vault Sensor. Model: ',> -y 3 O - 1Ftry ❑ Piping Sump/Trench Sensor(s). Model: i`f OW ping Sump/Trench Sensor(s). Model: '�-0- 13 WSump Sensor(s).Aoki"S Model: .tee ❑ FASSump Sensor(s),�9p,g3 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(specify ui ment a and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on—Page 2). Ta ID: 16�WC' �' Nw 1 IC 1p�� Tank ED: li�Tank Gauging Probe. ❑ In-Tank Gauging Probe. Model: P Annular Space or Vault Sensor. - vo 7 ❑ Annular Space or Vault Sensor. Model: if Piping Sump/Trench Sensor(s). 13 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). 2-0 fl' ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other 02ecifZ equipment a and model in Section E on Pa a 2). ❑ Other(specify ui ment type 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). ❑ Shea Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ElDispenser 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 Moat(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Mode): ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment 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 infornmtion (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring 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 ` f � Technician Name(print): �3'/'P ..(/// N fw /-A106 Signaiwc: z"--6-01e4 Certification No.: d License No.: Monitoring System Certification