COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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a �UALITFTES TING OF UNDERGROUND 7ANKSATAFFOR DABLERATES' Post ce Box 36 Thornton, Ca 95686 � � FAX 794-®112 u General Information MAR '13 200 Facility Name: ,:U/L' / -� Bldg.No.: Site Address: _ Ci - �` f 1 � fis Zip: Facility Contact Person: _ Contact Phone No.: ( ) Make/Model of Monitoring System:_V, { k5 h Date of Testing/Servicing: B. Inventory of Equipment Tested/Certiried rTank]]D: o riate boxes to indicate specific a ai ment ins ected/sereiced: e� Tank ID: ruging Probe. Model: /1 X41r;, ❑ In-Tank Gauging Probe. Model:ace or Vault Sensor. Model: `'r ❑ Annular Space or Vault Sensor. Model: p/Trench Sensor(s). Model: "7 r) ^ .< '�` ❑ 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specifj 22uipment tyee and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on PaLe 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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: 17 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 1 ❑ Other(SRSEa E2uipment e'and model in Section E on P!Le 2). ❑ Other(speci2 a ui ment Band model in Section E on PaLe 2). Dispenser ID: Z2/`41 ®{ Dispenser ID: / ❑ Dispenser Containment Sensor(s). Model: ❑ 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: 0 f sir 1 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Pi ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 13DisEenser Containment Float(s)and Chain(s). ❑ Dis enser 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 equi ent capable of generating such reports,I have also attached a'copy of the report;(check aft that apply): ystem set-up Alarm history report Technician Name(print): L I I Pt t'Y�� Signature: '�� ' J . �� ,... t_/ / . i,��-=7-'_ a Certification No.: + License. No.:_h&L C1rj 1! L13 1 CC # 52,Ari 1 15.- L Monitoring System Certification