COMPLIANCE INFO_1996-2005 - Laserfiche WebLink

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(a ` A 14 ( � f fa rj' a 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' i' Post Office Box 36 Thornton, Car. 95686 (209) 794-0102 FAX 794-0112 d~ General Information Facility Name: _L-m T OUc—i ( 9 ��r Bldg.No.: Site Address:—a--2:57 W Uoc City: LoCU Zip:_9 SZ(-f Facility Contact Person: Contact Phone No.: ,( Dq 1 — 1®-S13 Make/Model of Monitoring System: I W-0 l Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check e aggropriate boxes to indicate specific equipment ins ected/serviced: VTankID: 7TA, ID: G I Tank Gauging Probe. Model: -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: nnular Space or Vault Sensor. Model: ing Sump/Trench Sensor(s). Model: ping Sump/Trench Sensor(s). Model: Sump Sensor(s). Model: ❑ F'1 Sump Sensor(s). Model: chanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model:ctronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: C£Other(s eci ui ment a and model in Section E on P21e 2). El Other(s ui ment a and model in Section E on Page 2). T ID: Tank ID: -Tank Gauging Probe. Model: L3 In-Tank Gauging Probe. Model: �anular Space or Vault Sensor. Model: F,15 13Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: LI L4 ❑ Piping Sump/Trench Sensor(s). Model: C3F amp Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: echanical 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: [Dispenser her(s Equipment typeand model in Section E on Pa a 2). ❑ Other(s eci a ui ment a and model in Section E on Pae 2). raser ID: 4 a D' eraser ID: spenser Containment Sensor(s). Model' tA`g eraser Containment Sensor(s). Model: u 6.5 ear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). user ID: 3 i D' er ID: `c penser Containment Sensor(s). Model: t.d penser Containment Sensor(s). Model: ear Valve(s). Shear Valve(s). s enser Containment Float(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). ID: Dispenser ID: spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ear Valve(s). ❑ Shear Valve(s). enser Containment Float(s)and Chain(s) 1 ❑ 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. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring: pment: For any a went capable of tipg such reports,I have also attached a copy of the report;(check all that apply): System set-up lar r ort Technician Name(print):Zane Nil m M- E°9 Signature: Certification No.: RJ License o.: 7 Monitoring System certification