COMPLIANCE INFO 1996 - 2004 - Laserfiche WebLink

Home Browse Search

------------- Y � l 96a_P QUALITY TESTING CIF UNIDER(;R01JN0TANKSAT AFFORDABL E RATES' I Post Office Box 36 Thornton, Cc. 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: L-A -rHP r> P —.�C..�-(6u Imo Bldg. No.: Site Address: j b e L fjT E WI p�r City: L-X T E IE£y Zip: Facility Contact Person: E2a OK -�C�kJ L�..__ Contact Phone No.: (9 p9_) qj gj Z--° 5-]79 Make/Model of Monitoring System: GI L / 2C 0 1-) C _ Date of Testing/Servicing: /j 12a0 ! B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate specific equipment Inspected/serviced+_: Tank ID: 87 _-74 eve Tank ID: Ak In-Tank Gauging Probe. Model: rn AG 2 A In-Tank Gauging probe. Model: IT'S Ara � Annular Space or Vault Sensor. Model: 0 $ ll u Ck Annular Space or Vault Sensor. Model:{ L 11W�nrr� !!Piping Sump/Trench Sensor(s). Model:_ CKPiping Sump/Trench Scnsor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: JR Mechanical Linc Leak Detector. Model: !. Z ). Mechanical Line leak Detector. Model: 2 -5 9!5 Electronic Line Leak Detector. Model: _ Cl Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ © Tank Overfill/Iligh-Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: __-_^ _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floal(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Other(specify equipment type and model in Section k on rage 2). ❑ Other(specify equipment type and model in Section E on Page 2), Tank ID: %7 _7s+ +�� Tank ID: _ In-Tank Gauging Probe. Model:�INl16-7i U In-Tani`Gauging Probe. Model: - JWAnnularSpaceor Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: _-_- W Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: - ❑ Fill Sump Sensor(s)_ Model: Of mill Sump Sensor(s). MOM:, Mechanical Line Leak Detector. Model: a 161 19 ❑ Mechanical Line Leak Dctecloy..-"M' odel: ❑ Electronic Line Leak Detector. Model: ❑ Glectronic Line Leak Delject-ijr. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ 'rank Overfill/I lighgrevel Sensor. Model: n ❑ Dispenser Containment Sensor(s). Model:— Y ❑ Dispensertainment Scnsor(s). Model: ❑ Shear Valve(s). ❑ Shcar yarve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Did enser Containment Float(s)and Chaln(s). ❑ Other(specify equipment type and model in Section F on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). 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 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,history report. Technician Name(print): /ac t�G /,j I r" + _ Signature' -- Certification No.; Z /8) License. No.: Phone: No.: