COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

to 1 - RECE U 1 MAY 3 1 2006 , 'QUALITY TESTING OF UNDERGROUND TANKSAT AFFORDABLE RATES' ENVIRONMENT HEALTH 416 2nd Street Galt, CA 95632 (209) 744-0112 1!WFW1W (�eneralInformation 17 / Facility Name: _ ( / 6 e C Bldg.No.: , Site Address: _ l6 1�?© CfiFMBQIDGt(C City: TI{QDtoZip: q5336 —� Facility Contact Person: L( 2- Contact Phone No.: ( a? ) 6 61--Y((,6-- Make/Model of Monitoring System: V'E(%D kj2 0007 '(C-S- 35e' Date of Testing/Servicing: .E/_LJ/ D6 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate ecifc equipment ins ected/serviced: T ID i5-7 Tank ED: ank Gauging Probe. Model: t ❑ In-Tank Gauging Probe. Model: Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 208 13 Piping Sump/Trench Sensor(s). Model: ❑ F' Sump Sensor(s). Model: ElFill Sump Sensor(s). Model: hanical Line Leak Detector. Model: -MCD ❑ Mechanical Line Leak Detector. Model • 13 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(speci in went type and model in Section E on Pa 2). ❑ Other(specify equipment type and model in Section E on Pae 2). T ( o c� Tank ID: auk Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model nular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:.STP-M t-h ❑ Mechanical lane Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Levet Sensor. Model: ❑ Other(s tri ment type and model in Section E on Pae 2). ❑ Other(specifv equipment type and model in section E on Pa 2). Dispenser ID: 1 'F Z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: X-Shcar Valve(s). ❑ Shear Valve(s). is ser Containment Floar(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: +'A, Dispenser ID: � ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). - Model: hear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). 13Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ DispenserContainment Smsor(s). Model: ❑ ShearValve(s). 13 Shear Valve(s). ❑Dispenser Containment Ploat(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 (eg. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring egpipmenL- For any eq --patient 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): Z qAt F t'mn2� Signature. Certification No.: License.No.: Z'(/ SZ(, ? - ( T 077<_ It Ci4- IGjto Monitoring System Certification �'T