COMPLIANCE INFO_2005 - 2010 - Laserfiche WebLink

Home Browse Search

(209)#4-0112 Jan 20 05 09: 39a Affo a-Test P• 2 1 t 17 1 i r" -11 Df tar/ jN f f arba ZrAt 'QUALITY TESTING OF(INDERGROUND TANKSAT AFFORDABLE RATES' ?en Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 Information Morada ChevronFaci �1i A �" Bldg.No.: - Nat l't .'.� >LJ�r7 �..s�, zip: Site Address: JO= r'V r��iUv� City: S �- /IJ'D T p P i !r3✓ — �S� Facility Contact Person: AU!-- � Contact Phone No.:(( ;-41 _ Makelmodel of Monitoring System: ^• l ' Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check tbt alllate boxes to indicate anecific ui nevt i ted/servicd: Tank ID: (.L Tank ID: ❑ -Tank Gauging Probe. Model:- ❑ >jT�k Gauging Probe. Model: hr Annular Space or Vault Sensor. Model: 6` i Annular Space or Vault Sensor. Model Iq Piping Sump/Trench Smsor(s). Model: X Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: )21,Mmbauieal Line teak Detector. Model:�t'li TaP.(2.' FXTt/ $-Mechanical line Irak Detector- Mode1Cdl-Q� ❑ Electronic Line Leak Detector. Model: ❑ Eimtromc Line Leak Detector. Modeh ❑Tank Overfill/Higb-Levet Sensor. Model: ❑ Tank Overfill/I-ligh-Level Sensor. Model: ❑ Other(S eci ui Trent and model in Section E on Pa2c 2). (30dju(specifvenummentrypeand model in Section E on Paye 2). Tank ID: 4 i Tank ID: ❑ In-Tank Gauging Probe. Model: I 13 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: % et f7 P❑ Annular Space or Vault Sensor. Model: SGI� Piping Sump/Trench Sensot(s). Model: -R Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: -'-Mechanical Line Leak Detector. Model:i�r' �'pcY�'XT✓✓ .Mechanical tine Leak Detector. Model: d n Te4e Krh FXT✓ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spedfy equipment type and model in Section E on Pae 2). ❑ Other eti a ui [Hent and model in Section E on Page 2). Dispenser ID: Dispenser ID: �r"J ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). ❑ Sheat Valve(s). $Dia enser Containment Float(s)and Chain(s). 'P -Q Dis eraser Containment Roat(s)and Chain(s). Dispenser LD: t- b Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensoi(s). Model: ❑ ar Valve(s). ❑ ShearValve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dis nser Containment Floats)and Chain(s). spencer D' ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Nio'iel: _ ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis user Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). .If the facility contains more tanks or dispensers,copy this forth. Include information for every tank and dispenser at the facility. C. Certification.I certify that the equipment identified in this docomemt was impected/serviced In accordance with the manufacturers' guidehoes. Attached to this Certification is information (eg. manufacturers' checklists) necessary to verity 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): U System set-up ❑ALrm histery report Signaiw:: ` -J t, GsG-fir Technician Name(print): 'P . // -�--- Certification No.: �'"�- G� License. No.: Monitoring System Certification