COMPLIANCE INFO_1989-2008 - Laserfiche WebLink

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Af f QUALITY TESTING OF UNDERGROUND TANKS AT AFFORDABLE RATES' Post Oce Box 36 Thornton, Car: 95686 (209) 794-0102 FAX 794-0112 (general Information Facility Name: e r 11-n L s 1tOi-41k Bldg.No.: Site Address: de 1� 5 ity: J—rv;r 2dl�� Zip: G IL F 1 Facility Contact Person: Contact Phone No.:( ) Make/Model of Monitoring System:_ oaf /` Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate specific equipment iected/serviced: Tank ID: V1 Tank ID: i �P ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Conular Space or Vault Sensor. Model: Er-Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: )—, l 3-fi—ping Sump/Trench Sensor(s). Model: ;94, ❑ 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(s2ecia equipment type and model in Section E on Pa a 2). ❑ Other(s eci ui ment type and model in Section E on Page 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(sEeciLy 2quipment nM and model in Section E on Pae 2). ❑ Other(s eci ui ment type and model in Section E on Pa a 2). Dispenser ID: t) 14 Di a er ID: ) ' ❑ Dispenser Containment Sensor(s). Model:a CO?t?,r,, v&as e® 'spenser Containment Sensor(s). Model: 7<A 1.1 77 ,:�, ❑ 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). L3Shear Valve(s). ElDis 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 Contaimnent Roat(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.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 r t � I Technician Name(print): � !� �:/, l� t t-4a Signature: Certification No.: 'U ,--3L -fz License.No.: Monitoring System Certification