COMPLIANCE INFO_2009-2013 - Laserfiche WebLink

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- tuag. Ivo.: Site Address: e— `� tP City' a % Zip; Facility Contact Person: _ Z2 coo 0 t ®� Contact Phone No.: ) -41 1>6-- ✓��/� Make/Model of Monitoring System: - VR, TL5 .2-6-D t Date of Testing/Servicing: l //Z /_0 '7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: it -, e5 r- / Tank ID- Tank Gauging Probe. Model: _ Gi "O "' 13 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: =,g M 3 -'AiO9 iping Sump /Trench Sensor(s). Model: 9'P ❑ Annular Space or Vault Sensor. Model: +l u ❑ 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 (s ecu a ui ment type and model in Section E on Pae 2). ❑ Other (s ecu ui ment tyee and model in Section E on Pae 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: ❑ FillSump Sensor(s). Model: L3 Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment e.and model in Section E on Pae 2). 1 ❑ Other (sgeciLl a ui ment typd and model in Section E on Pae 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). ❑ 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). ❑ 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). *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 dominent was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. -monitoring manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of equipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check aft that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Lille1 Vxmmn Certification No.: f Monitoring System Certification Signature:_ex� V ' License. No.: _ qi - 103 1 CC 4 52.49 � i 5 -- L(1