COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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ffvrbaATr,$ 'QUALITY TESTING OF UNDERGROUND TANKSAT AFFORDABLE RATES' Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 WW Information Facility Name: k& ` 1 P, -T V,t2 jy e66> Bldg. No.: Site Address: 3a'37— E- ted', City: 5TC'C-1L?4:,0 Zip: 95005 Facility Contact Person: Make/Model of Monitoring System: 10 � � [S 1 e_> C----) Contact Phone No.: ( o-& -F ) �146 —:58 (. Date of Testing/Servicing: JV__I .z 1_eL B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/servicedt: Tank ID: 87 -rN Tank ID: 'q2- 0L-7 X0 E Gauging Probe. Model: Gauging Probe. Model:n-Tank Xn-Tank Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ''ping Sump /Trench Sensor(s). Model: �j Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line leak Detector. Model: .00'Electronic Line Leak Detector. Model: ,fd"Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill/ I ligh-Level Sensor. Model: ODispenser Containment Sensor(s). Model Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). O Dispenser Containment Floats) and Chain(s). O Dispenser Containment Float(s) nod Chnin(s). O Other (specify equipment type and model in Section I: on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: �>t L. Tank ID: _ O In -Tank Gauging Probe. Model: 14 In -Tank Gauging Probe. Model:.___ ___ __ __ ❑ Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: A' 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: _ _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill / I ligh-Level Sensor. Model: 8 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). O Other (specify equipment type and model in Section L• on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). 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 al/ that apply): ❑ System set-up ❑ Alarm history report. Technician Name (print): Q E �I m ✓n o Signature: _40�� Certification No.: L;U wI I?z, License. No.: W Phone No.: ( 2-09 ) 7 14 - 010 2-