COMPLIANCE INFO_1989-2013 - Laserfiche WebLink

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Facility Name: $A O SoAbu, �r�«, aT`t'l-��t----------------.___ _ .. _-------- Bldg. No.: l(o- AA Ac Site Address: �Oc�o--L��L( L L.)�y _ . _____ -___ C itY-.F-Crt!Y__� _ Zip: Facility Contact Person: �pB _ Contact Phone No.: ('209 r Make/Model of Monitoring System: mate of'Testing/Servicing: Iy / 1 /20D, I l B. Inventory of Equipment Tested/Certified Check the annronriate hoxes to indicate cnrrifir PnuinmPnt incnartad/carvinnrls• Tank ID: iZi iii -- J __--- ----_ Tank ID: _ V 0 In -Tank Gauging Probe. Model: ❑ III - Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: JXAnnular Space or Vault Sensor. Model: ..Piping Sump / Trench Sensor(s). Model: _ (Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ _ 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: _ 0 Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: _ _— _ _ ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floats) and Chain(s). O Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment type and model in Section L on Page 2). ❑ Other (specify equipment type and model in Section Eon Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model:__ _ - - - _ ❑ In= Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: — 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model _ _ O Piping Sump /Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: _ _ _— 0 Fill Sump Sensor(s). M.Per 0 Mechanical Line Leak Detector. Model _ ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector. el: _— _ 0 Electronic Line Leak I or. Model: 0 Tank Overfill / High -Level Se Model _ _ _ ❑ Tank Overfill / I I' evel Sensor. Model: 0 Dispenser Containment sor(s). Model: _ _—_ _ O Dispenser tainmenl Sensor(s). Model: ❑ Shear Valve(s). 0 Shear V Alve(s). 0 Dispenser tainment Float(s) and Chain(s). 0 Latspenser Containment Float(s) and Chain(s). ❑ O ify equipment type and model in Section E on Page 2). CI Other (specify equipment type and model in Section E on Page 2). 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) neeemry to verify that this information is correct and a -Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check of that apply): O System set-up AJ/A O Alarm history report. Technician Name (prin TTO SiI anathrre: _ I VF Certifiratinn Un • � _ _ �C- XI - Phone No.: `� og )_7 9 Y- 6 / 61