COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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0 AIM QUALITY TESTING OF UNDERGROUND TANKSATAFFORDABLERATES' JfPost Office Box 36 Thornton, Ca.. 95686 (209) 794-0102 FAX 794-0112 y General Inform tion: Facility Name: MSV Inform k-- lL90 oo T Bldg. No.: Site Address: 3_2_ City: 7 , 0,Zip: Facility Contact Person: Contact Phone No.: O Make/Model of Monitoring System: L4,? a ,�-z T5 /00/ Date of Testing/Servicing: / ?_a!!221 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insnected/serviced: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: `V d. ❑ Piping Sump / Trench Sensor(s). Model: %-SP 14 h-_5 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Pae 2). Tank ID: 54.4 P ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 7-5P ❑ Piping Sump / Trench Sensor(s). Model: Le 1_!52 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other 02ecifX a ui ment a and model in Section E on Page 2). Tank ID: Tank ID: 77 77 ❑ 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: 5A,2 S ❑ 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 (specify ui ment type and model in Section Eon Pa a 2). ❑ Other (sgecifl 2quigment type and model in SectionEon Pae 2). Dispenser ID: z- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: S ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) 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). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser 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). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) and Chain(s). '71 L11C 1QG1ULy GU11L4111J 111016 LMUL UAOF611061.1, WjJy UUP 1U111L 11161UUC lUlU11ASUU11 IUL CVCly UILIK WJU UMPULINCr ai 111C 11(;Wiy. 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 ofmonitoring 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 / Technician Name (print): L�` �2°e ® f� Signature: Certification No.: 0420 `�° 01152 License. No.: i° Page 1 of 3 03/01 Monitoring System Certification o