COMPLIANCE INFO_1989-2013 - Laserfiche WebLink

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rA i QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' E N V I R u N ivl 'Facility Name: Bldg. No.: Site Address: City: zip: Facility Contact Person: � 4.� Y-7 Cont06 act Phone No.: L2 I -L— Make/Modelof Monitoring System: Date of Testing/Servicing: 0 B. Inventory of Equipment Tested/Certified Check the a2eroeriate boxes to indicate ecific S2nipment inseected/serviced: Tank ED: 7-) 1 t s 1-,/ 1�/,_ T, , -) , S 0 , Tank ED: _77-s 7 7 E3 In -Tank Gauging Probe. Model: L i /4 L3 In -Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: L3 Piping Sump / Trench Sensor(s). Model: U Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: 13 Mechanical Line Leak Detector. Model: 13 Mechanical Line I&A Detector. Model: E3 Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: 13 Tank Overfill / High -Level Sensor. Model: 13 Other (specify equipment !y2e and model in Section E on Page 2). 13 Other (sgecify 2qui2ment t)" and model in Section E on Page 2). Tank ED: Tank 10D: E3 In -Tank Gauging Probe. Model: E3 In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: E3 Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: E3 Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: L3 Fill. Sump Sensor(s). Model: E3 Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: L3 Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: 13 Tank Overfill / High -Level Sensor. Model: Q Other (sequiLxLent e and model in Section E on Page 2). 13 Other (seecifX EquipMent Lypd and model in Section E on Pa e 2). Dispenser ED: Dispenser ED: 13 Dispenser Containment Sensor(s). Model., 13 Dispenser Containment Sensor(s). Model: E) Shear Valve(s). El Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). El DisEenser Containment Float(s) and Chain(s). Dispenser ED: Dispenser ED: El Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: 13 Shear Valve(s). 13 Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). E3 Disgenser Containment Float(s) and Chain(s). Dispenser ED: Dispenser 10D: 13 Dispenser Containment Sensor(s). Model: L3 Dispenser Containment Sensor(.-). Model: 13 Shear Valve(s). L3 Shear Valve(s). 13Diseenser Containment Float(s) and Chain(s). L3 DisEenser 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 of inonitoring equipmeriL For any equipment capable of generating such reports, I have also attached a' copy of the report; (check all that apply): E3 System set-up 0 Alarm history report 4, Technician Name (print): L P 1N Amrno Signature: I Certification No.: 2. 2 License. No.: C117 - i i�3 I CC. 62.49 N 15 -- LOF Monitoring System Certification