COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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Air A AvIL 7A f farba—,'T i L.. QUALITY TESTING OF UNDERGROUND TANKS AT AFFORDABLE RATES' Post Oce Box 36 Thornton, ear 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: L W rps n G e Li V e r m o r e- N(0_- ono_( Lo-b Bldg.No.: Site Address: 013 - C o r ro_\ o i 1 c> u) Pd City:_-T-rd-0-r i Zip: tl J 3`7(.,p Facility Contact Person: V fes( ( oraContact Phone No.: ( 9 :J ) 'IZ2. - '7q3l Make/Model of Monitoring System: !,(?G�'I-C,6 ov e Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the agerogriate boxes to indicate edfic equipment ins ected/serviced: FTa,n,k ID: Tank ID: n-Tank Gauging Probe. Model: 13In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:�4/3 �`�. 13Annular Space or Vault Sensor. Model: 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify!quiment=e and model in Section E on Pae 2). ❑ Other(sEecifl 2quiLr2ent a and model in Section E on P!&e 2). Tank ID: Tank ID• ❑ 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: ❑ 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(sEecify Squi=t type and model in Section E on Pa a 2). ❑ Other(specify ui ment type and model in Section E on Pa a 2). 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). ❑ DisLenser 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). ❑ 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 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 n Technician Name(print): �� Signature:_' � Certification No.: 1_5License,No.: Monitoring System Certification