COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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f forba.-I - ___ � _�_ , i � F'(" _,"T 1_1 I t[E DD 'ftl11AL17T TrtWINr, OF'( IM11FR(WOUMI) 7AMKS 117 -AFT [ROA& jlq7-T003 Post Office 13or _1( klo0j,1 75; 1,D to / U. Itivetitol-y of F4111111111elit 'I'e'sle•fl/( 'e•rlilit•11 (heck the aoorovrlate boxes to Indicate saeclflc euuinment InsocctrJleer vlced: 79"ft11"A,,1F4,VE7A?fjO112 PERPoi fiSERVICES Tank ID: LA 'Tank 11): g LI 1A -Tank (longing PmMr. Mretrl: � __ U In-Tilrok (rouging P►l/hr. Y- — Model. _ M.;r }A �pular Space or Vault Sensor. Modr1: ?'S —FZi S �ru1ro Spare (lr Vnnit Sensor. Model: QJ -r-z S ErPiping Sump / Trench Sensor(s). Model: fi,G P" Lr S t g Sump /'I'►rnch Sensnr(s). Model: T S 0. Ee 1--5 C] PO„Sump Sen+nr(+). Mor1e•1' U Dill S'ntup Srunnt(s). Mudel: kiechanical Line Leak Drierim. Modfl.Lt7 el: _ , ti}-1CVe6nnicnl [.file I enk Drteclor. Mnrlel: � ),..J7 O Electronic Line Leak Detector. Modrl: U Fircnnnic Line (.rnk Detector. model: O Tank Overfill / Iligh-1 evel Sensor. Model: U 'Tank Overrill /I ligh-Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). U Other (specify ui ment type and model In Section E on Page 2). Tank iD• f 1'nnk Ith l/ U In -Tank Gauging Probe, Model: _ U hr -Tank (lnuging Probe. Model: ❑ Annular Space or Vault Sensor. Model: tom► tune Space nr Vault Sensor. Model- ❑ Piping Sump I Trench Sennor(s). Model: Wi aping Suntp /'Trench Semor(s). Model: T5 P �t 5 ❑ Fill Sump Sensor(s). Mrxlel: _ U pii 1 Sump Srusnt(s). Model: _ ❑ Mechanical Line Lenk Detector. Modrl: WMerhanical Line I enk Defector. Mrxlel: ❑ Electronic Line Leak Detector. Mrxlel: U Flectronic Line Lenk Defector. Model: ❑ Tank Uverfil) / Nigh -Leve) Senaor. Mnrlel: U Tank Overfill / i ligh-1 evel Sensor. Model: Other (specify i ment type and model in Sectiurl L? on 1'a e 2). U Other (specify equipment ment t and nxrllel in Section E on Page 2 • Dispenstt iD: _17— Dispenser 11): U Dispenser Coinlailnllent Srnanl(s). Mntlrl: 'r5) 11- 7 U Dimprosel (11111nin111r1U Sellanl(s). Mfidel: U Shear Valve(s). U Silent Vn)ve(s). ❑ Dispenser Containment float(s) and Chnin(s). IU U Dispenser Containment Fioat(s) and Chains . Dispenser iD- µ Dispenser 111: - ❑ DispenserConlninnient Sensor(s). Model: S_G� u_I--.S..� __ U Dispenser Containment Sensor(s). Model: O Shear Valve(s). U Silent Valve0). LI Dispenser Containment float(s) and Chain(s). U Dispenser Containment Boats and Clinin"s . Dispenser ID: j *- & _ Dispenser ID: ' ❑ Dispenser Containment Sensor(s). _ Mlnlel: U Dispenser Crnitainment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). LIDisEstiser Containment floats and Chains , U Dispenser Containment Floats and Chain(s). n u1e tacfufy cnntams tntne tnntcs nr lnspensels, espy this tion[. hlrlodrill formation for every tmrk and dispenser at the facility, C. Cer(inclllion - i certify that the egnlpnrent Identified In fhls document was hispectrlUserviced In accordance with the manufacturers' guidelines, Attached to this Certification is lnforlmtlon (e.g. mnourachirers' checklists) necessary to verify that this Infotmath m is correct and a Plot Plan showing the layout of mmdluriuR egnlpinent. For any equipment capable of generntiolt such reports, I have also attached a copy or the rep ret eherk af/ rhaLapp�'yl.0: U S,yptrm Mel-ulr U rn aliirfepor�°` ----- Technician Nnn1r (print): 4y� P"k) %qtr 6;s Gf Si�nnllne: ! Cerfifiration No.: ?-'001� D`'� I.irrnse Nn. 1'nRe 1 411`3 03101 Monifor(nR System CerfIncot(mi V