COMPLIANCE INFO 2007-2012 - Laserfiche WebLink

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lrrtl�uri C'ire�(' C h�rpter 6 Z Heolth nr Iiye �.Sn�'��1Tru cfe;r f Jhct-xtliciIUplcrbf?, D*lsrrxl��i7�lfr?3-I('ufifra,nic•(wife This form must be used to document testing and servicing of monitoring equipment. Aft certific tri 'ulrrrir�rz. re ared for each monitoring s stem control anel by the technician who performs the work. A copy of this for r the tank system test d operator. The owner/operator must submit a copy of this fonn to the local agency regulating t within 30 days of test date. �a g Y g , UST systems A. General Information JUN G 3 200$ Facility Name: Site Address: .] Ic - IAN.-IL-1— Bldg.WIR©NMENT HEALTH `1..� City. S F Facility Contact Person: 370,1Al �L� 1 Zrp:� R_S Make/Model of Monitoring System: �t �, T Contact Phone No.:( )ti�5': y, B. Inventory of EQttipirnent Tested/Certified Date of Testing/Servicing: Check the a ropriate Ixrxes ra indic:rh-sperific egoirrment ins ectedb;erviced: Tank f D: - 01 In-Tank Gauging Probe. Tank iD: 6 Model: E Ail In-Tank Gauging Probe. Model: 14+ el Annular Space or Vault Sensor, Model: W Annular Space or Vault Sensor. Model: Il Piping Sump/Trench Sensor(s), • 4 Model: lI$ Piping Sump/Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: Model: 0 Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: Cl Electronic Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: i S'G 4i j Tank Overfill 1 High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ( ment a and model in Sentian E on Aa e 2 . Q Tani"Overfill/High-Level Sensor. Model: ❑ Other(s ecify a u 'Tank ID: ' ) LlOilier(s c( a ui rnent t e and model in Section E on Page 2). � T nk 1D: ® 1n-Tank Gauging Probe. Model: m/k. ' UN Annular Space or Vault Sensor_ Model: ❑ nk Gauging Probe. Model: &I Piping Sump/Trench Sensor(s). � ❑ Annular or Vault Sensor. Model: Model: ZG' ❑ Piping Sump f h Senso s . L7 Fi(ISumpSensor(s). Model: �"( ) Model, Mechanical Line Leak Detector. Model:_ L{!r?t,e,� C1 Fill Sump Sensor(s}, el: J Electronic Line Leak Detector. Model: --� ❑ Mechanical Line Leak Detecto odel: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak r, 0 Other(specify e ui ment type and model in SectionE on Pa e 2 . ❑ Tank r1 -Levet Sensor. M)del: Dispenser ID: Other(s ecify e ui merit a and model in Section Eon ) B Dispenser Contaim nent Sensor(s). Model: ¢� 1)tspenser ID: s - GYShear Valve(s), — Er Dispenser Containment Sensor(s). Model: ~� Zt ❑ Dispenser Containment Float(s)and Chaa-Shear Valve(s).in(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Ij� (a'Dispenser Containment Sensor(s). Model: Dispenser ID: '7 S vr ' k] Shear Valve(s). ��-�_ •0'Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Float(s)and Chain(s), gShear Valve(s). Dispenser ID: ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: LI Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑Dis nser Containment Floats)and Chain(s). ❑ Shear Valve(s), ® Dis -it tnser Containment Floats)and Chain(s). he facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify than the equipment identified in this document was ns?pected/sc cd ��a accordance with the manufacturers' guidelines. Attached to this Certification is infotrrration (e.g, m:rnufreturers' Checklists) necessary to verify that this information is correct and n Plot Alan showing the layout of monitoring equipment- For any equipment capable of generating such reports,I have also attached a copy of the report;(check till!/far applt.J: $ ste set-u Technician Name(print): y Alarm history report Signature: Certification No.: 3 Cl S" lC C �' S2 3-[lT License.No.: L . � Testing Company Name: Site Address: Phone No.: Date s of Testing/Servicing Monitorin S -senCer•tifiettion Page I of3 ta3ra r l�. I e�lllts of Tes;tili /Servi€illp