COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

niffty ' - r 1 QUALITY TESTING OF UNDERGROUND 74NKSATAFFOXDABLERATES' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Informatiop Facility Name: S f o CBldg.No.: Site Address: (o3 a J S. Z_im f:KG. City: -7 Vie^tri lip: 'y'{ O^ Facility Contact Person: T(eEN t 6)a OLO t E Contact Phone No.: ( ) /rte/—/6.4:�L Make/Model of Monitoring System: jFN!'(9h /Ot)D.FiZ1 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced. Tank ID: a V L ce# f ;)_ DOC) Tank ID: BIn---Tank Gauging Probe. Model: /"l?a4 ❑ In-Tank Gauging Probe. Model: II-) nular Space or Vault Sensor. Model: TST1:/"/=L Ly ❑ Annular Space or Vault Sensor. Model: Q-Piping Sump/Trench Sensor(s). Model: TS p U A-S. 13 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: 2'lilectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Pae 2). ❑ Other(specify ui men[type and model in Section E on Pae 2). Tank ID: Tank ED: El In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: -46 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: CI 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 men[type and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 4t / Dispenser ID: ❑ Dispenser Containment Sensor(s). Model:TIC,00— bl�_15 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: *" Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: .U J„ S ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). LlDiS 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 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 o copy of the report;(check all that apply): ❑System set-up ❑Alarm history report Technician Name(print): Signature: l Certification No.: '� int ?�' License.No.: Page 1 of 3 03/01 Mn,ifn .Qv fnm V 'fifiraf inn