COMPLIANCE INFO_1989-2013 - Laserfiche WebLink

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__...-�..�.1wi.* ,.....�...,.�. �. V„�,..,..a _..._ _.._. ,...__�....._�,� �� .r..,s.....w.. ....y...,_...-...,.. - �, m_.._w .�.�.�.�.,.v..a.� .,.,.,..... v.._... {*4'FEB 4 • U TES' dro'�4�'9112 Post Office Box 36 Thornton, Cit. 95686 (209) 70- .*HiEfiT Information Facility Name: 1�':p m Site Address: _7000 �" Bldp,. No.: City: _ / s c �t q'�/�, %dip: `I'J f Facility Contact Person: 3O �CJ �� t 1 la [ I i � Contact Phone No.: ( �� -�� Make/Model of Monitoring System: _ f dr ry�Y S Date of Testine/Servicinu- � tom/ io5 B. Inventory of Equipment Tested/Certified Check the aDDronriete hnipe to i—n—to Tank ID: 27 -, e y ❑ In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). 13Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (sEeciLy Equi2ment tyRe and Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and r Dispenser ID• ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s) ❑ Shear Valve(s). Model: Model: Model: _l S Model: Model: Model: Model: nodel in Section E on Page 2). Model: Model: Model: Model: Model: Model: Model: yodel in Section E on Page 2). Model: Model: Model: -vispenser Containment Float(s) and Chain(s) *If the facility contains more tanks or dispensers, copy this form Tank ID:/� J — 5 '-"/ /V®% ❑ In -Tank Gauging Probe. 4 Annular Space or Vault Sensor. Model: Model: L 0 d � .# Piping Sump / Trench Sensor(s). _ Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci equipment a and model in Section E on Pa2). Tank ID: Le ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis nser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: U Shear vaive(s). ❑ Dispenser Containment Float(s) and Chain(s) 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 inforutation 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 all that apply): ❑ System set-up ❑ Alarm his tery report /- Technician Name (print): �� f/, %C/ l �� 6�� Signatui:�� d Certification No.: P- License No.: Monitoring System Certification