COMPLIANCE INFO 1987 - 2007 - Laserfiche WebLink

Home Browse Search

..� Ssv - 'QUALITY TESTING OF UNDERGROUND TANKSAT AFFORDABLE RATES' PGneral ffice Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 ormation ,y�FacilityName: pp Bldg.No.: Site Address: 12-"" Ida. t( of r^'64 t 6 g WO tF City: S l[i : it}(`tl%pl . e*, Zip: �/C✓I,--�GS� Facility Contact Person: T" Af P—itt Contact Phone No.:( 4P Oil) �`/ Make/Model of Monitoring System: CNI'l n)TFC ( �- '�E4's`000 Date of Testing/Servicing: �� =i,�T B. Inventory of Equipment Teste(Wertified [heck the appropriate boxes to indicatespecific a ui aient inspected/serviced: Tank ID: 15 m a Tank ID: OJn-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: k-YJ � - C1'Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: PA 13 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Smsor(s). Model: El Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Q 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 Page 2). ❑ Other(specify ui men[type and model in Section E on Page 2). Tank ID: Tank ID: 13 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill/Higb-Level Sensor. Model: 17 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(siawify equipment a and model in Section E on Pae 2). Dispenser ID: F rZ... Dispenser ID: 7y 1t y' ❑ Dispenser Containment Sensor(s). Modell ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 13 Dispenser Containment Float(s)and Chain(s). w <, ❑ Dispenser Containment Float(s)and Chain(s). r-e Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). ❑ ShearValve(s). _ LDispeuser r Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ID: Dispenser ID: r Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: lve(s). ❑ Shear Valve(s). 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 infunnation 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 C r Technician Name(print): 4'3/ t "o Signalm:;: /� ,a't. +f --:f'•a."`.s Certification No.: Q':'fr License No.: T 7 A " Page I of 1 03/e1 Monitoring System Certification