COMPLIANCE INFO 2004 - 2007 - Laserfiche WebLink

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je 1.itis Form mast be used to document testing inti ._-ML ni Mcllili, -:!Ii ctlutttmcru •` scva i -°1'1iu31lon or catiII :must ' pr,narui or each ;noniLo IM sr5lctt;_gniml-Ciallsa .:1c cch . .. -:;:, wiforms the ciork. copy of this !brut must be moviaeu to tine tank system owner?operator. The owner/operator must uh:n:i i :;yon of this form to the local agent re� auir ulsg UST s<stems within 't)dans of test date. - A. GeneralInformation F;tcdir, Name: ._f-Cq�(/ Sante Starion.No.. Site�ddress: -Lam{ -�y i+�_0 41��C /�a C City e__�✓�tC t =ip Facilitt Contact Person: �Ole� ��P�✓° t SS- Contact Phone uo.. !Make;Llodei of vtonitaring S+srem: �@rVRN 1�7^ - _- este ol'Tesiin�Scntcc: 1L_Z`�_ py B. Inventory of Equipment Tested/Certified t'heck the appropriate boxes nt indicittC 9peci6c equipment ittapectedlservir,.ed:__ _�ea...,. _ Ts k @ - _ T 1D- Z p eSe ?tfn}wGanging a ging Probe: Model cL nECJ�(� -Tank Gauging Probe Model Qct_ c�d0 mace or Vault Seng Motel �YowTS'�r=t c et �C 'alar Space or`v atilt Seng Model. �. , [�t� iptag SumptTrench Sensor ts). Model -_ltiveTsyLTc L�7Ptptng Suntpl renes Sensor is): 4ktdei. ❑Fill Stamp Sensor is). Model _ tDFill Sump Sensor(s). :Motel: ;_�Mechantcal Line Leak Detector. Model: __ ❑klechanicat Line Lcak Detwor. Motel: CElectromc Line leak Detector Madel: -� OEle.-trunic Line Leak Detector ModeL CT,:ank OvertilUHigh-tevel Sensor: Model: -T - CTank OverflUfRigh-level Sensor tvlodd: — -- CIIthe r. pecili c uia. n pe atad mock l in StxYion E on PaEc_ []Chher St e afv- �tup rt a and model in Section E on Page Tank ID _ Tank ID _ _ +[]lr-Tank Gaugng Pmbe: Model -- _ - ; CIn-Tank Gauging Probe Motel -- --! ❑Annular Space or Vault Sensor. Modet. - ❑Annular Space or Vauu Sensor Model CPiping Sumpr T reach Sensor(s)- Model- -- ❑Pitanr Sutnpi Trench Sensor tsl. Model CF'ill Sump Sensor(si: Madel' CFill .rump Sensor Is): kiodel: OMechamical Litre L ak Daccror Madel _ CMechanical Line Leak Deseclor. Modei. CElecniorie Lia: Leak Detector Model: a []Electronic Line Leak DetectNwioteL []Tank GverfitUHigh-levet Sensor: Model: + []Tank thatiil iHigh-ie:ei Scntsur Model: - COthe . Spectfi equip. Noe and model in Section Eon Pam Ocither Smith-c nip- tvoeand_nmdei m Section E on Page ' Dns � r (D: -�Z -_ -_ _ D- user ID: -_3hspenserContainment Sensors: Model: jr/..nq.kr � yspenur Contaitunent Sa:nsartsf--- Modet:.�(o�'�TL. L-'�hear VaNe(s). r,5n,Shcar valve(s). :113isoenser Containment Floatisl and Chain(s) :lDisperser Containment Floatw and C hauut ii_ Dispense ID. Dispenser fD: []Dispenser Containment Sensors: :Model: CDispeaser Containment Sensartsi. Motel: - -- _-_-- _ '-' Shear Vahets). - pp C Shear Valveist. CDispenser Contautment Floa[tsl and Chainist 9 []Disvense.r Containment Flcat(s)and Chaul Disperser TD7 Dispenser ID- ❑iDispcnscr Contaitmteni'Senors: Model --- - -- ODispenscr Comainmcm Sensortsi:- Model: -_-- G Shcu Vaivetsi. ❑ Shear V'ahetst. Di�pense Containnmemi Floantsi and Chaartsi _ - __.� �Dispenser_Contammrnt F oatis+ and Chumsi `;f•hc iitcilin ;ontmns more :auks or dispensers, ::opv this forTn Inciladc information for even- ?.Ink:end dispenser at this ractiity --_ C Certification - i certift that the euuipment identified in this .tncumeat co was inspected/serviced in Acrdance with th< manufacturer' ezuidedines. .lttached to gain e'ertitieatutn is intotmation <e.lg. manufacturer' _tecl.•listst necess n ut :crifr that 'hi, iotnrmatim is zorrect and A Plot Plan ,howine the iavout 'It mtmiuminr: :quiptnent. For In% .:yuapmeat capahic'R 2,eneratine• ,[]cit -epnrs hale Also attached a cons, 1i the Armor: ,`[]trek aU Akar j.*y): , "-stem set-orf _ 71 kla iston re"O t CdhmcanNnnte Printi: ri-rhS_ �ignutur SSSSSS/CCrrr077✓/\ :-Ification No stmt 'ompans varpe: hamatan ?rc tsion r._- ';:•.