COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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r [,-or Usc By.Ill,/urisdre/inns hl ilhin Ilrc .Slnlcu/( uli/irrniu qulhori1v C'iletl. C7rcrpler•(J, f/eullla arnl.5'u/clr�C'orle C'ht/per l6 Dn rerun 3 1 isle 3�, C'crli/or rain('n�lc�crf rrl Born This form must be used to document testing and servicing, of monitoring equipment. A seG�arate ceititic or report�� be prepured for each III onitorinn system control panel by the technician who performs the work. A copy of this forte �1rovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency 0 P R 74t }ns within 30 days of test date. 60 A. General Information ` � Bldg.No.: Facility Name: City: O Zip: (9 rza(D7 Site Address: Z- i G 50s Facility Contact Person: V Contact Phone No.:( ) Make/Model of Monitoring System: CaT _ Date of Testing Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Ta nk ID: rjAk nk ID: In-Tank Gauging Probe. Model hr-Tank Gauging Probe. Model ts7 Annular Space or Vault Sensor. Model: AI Annular Space or Vault Sensor. Model Piping Sump/Trench Sensor(s). Model: 1/D Piping Sump/Trench Sensor(s). Model:Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: $ Mechanical Line Leal:Detector. Model 1 ai L-P7_00 ❑ Electronic l Li Leak Detector. Model: Oleodel: 9 El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify e ui ment ty e and model in Section E on Page 2). Tank ID: ®C_T Tank ID: 1 — )E(I In-Tank:Gauging Probe. Model: 4AQ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: �O ❑ Annular Space or Vault Sensor. Model: jR Piping Sump/Trench Sensor(s). Model: b I�Piping Sump/Trench Sensor(s). Model: F1 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 1�Mechanical Line Leak Detector. Model:�q� F ical Line Leak Detector. Model• `9q 2 ❑ Electronic Line Leak Detector. Model: ic Line Leak Detector. Model:erfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ecify e ui.ment type and model in Section E on Pa a 2). ❑ Other(speer a uirepent ty a and model in Section E on Pa e 2). -Z Dispenser ID:ID: ❑ Dis enser Containment Sensor(s). Model: er Containment Sensor(s). Model: ,y� P ULShear Valve(s). &Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: / Dispenser ID: 3 `� U ❑ ser Containment Sen or(s). Model: El Dispenser Containment Sensor(s). Model: EJ Valser C(s). 6 Shear Valve(s). Cd=Dispenser Containment Float(s)and Chain(s). 2-Dispenser enser Containment Float(s)and Chain(s). t p Dispenser _-(-_- f Z 0[Dispenserspn er ❑ Dispenser Containment Sens r(s). Model: ❑ Dispenser Containment Sensor(s). Model: 1 Shear Valve(s). 0-;Shear Valve(s). 12Ws enser Containment Float(s)and Chain(s). :kr Dispenser Containment Float(s)and Chain(s). *lf 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 equipment capable of generating such reports,I have also attached a copy of the report;(check all that npplp): U-Systen -u 43 Alarrn history report�® Technician Name(print): 7-41, me) Signature: �rle_ w 52 6:33.:2.7 617- Certification 17--•Certification No.: �/'A� License.No.: 61Tj tx 04 -I to f7, Testing Company Name: A. Phone Noj,20 )'74-1 f D 0.2. Servicing: Site Address: i Date of Testing/ l/� �� Paget of 3 " 03/01 Monitoring System Certification D. Results of Testing/Servicing