COMPLIANCE INFO_1996-2008 - Laserfiche WebLink

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VUALITY Tr!.WING 01;' UWW N/WOUNI) 7A1VKry .VATArFY)1?1)AnL RA72F. , I Post / r568?5___� W'j�ijj IF "General Information Facility Name: W,( Site Address: Facility Coninct Person: , V 'e V-- Make/Model (if Monitoring System: Yp "/" 1 77 11. Inventory of Cbeck the appropriate boxes to Indicate speclnc equlpn)cnt firspected/ses vired: BI(ig.No.: Cify:. �j 4 Zip: Dnif. fit 'I f-stilig/Sri vicitig: .6 - Tank ID: Tank 11): 0 In -Tank Gauging Probe. Model: U In -Tank Gauging Prolic. Model: R—A limiter Space or Vault Sensor. Model: "tn Spacit or 1101 Scsor. Model: >' Sump I Trench Sensor(s). Model: c U iping Surnp / Trench Sensor(s). M odel: 0 "6r"5'0 'P, ,,,S F "if) Sensor(s), Molivi: U Fill Siotrip St-nRoi(q). Moflel! -if -Mechanical Line Leak Deircloi. Model - 9, 7-P- 0 1"tr Y Ld-KI-r-chrinicid Line I enk Detector. Model: -057'6 Sr"r Al L 2 El Electronic Line Leak Detector. Model: U Flectronic Line Leak Detector. Model: U Tank Overfill / Iligh-Level Sensor. Model: U Tank Overfill / I ligh-Level Sensor. Model - E3 Other (specify equipment type and model in Scctioii,E- oil Pope 4 S U Other �specify equipment tXIM and model in Section H on Paso 2). Tank ED:• Tank ID - 0 In -Tank Gauging Probe. Model: U In -Tank (ratiging Probe. Model: E3 Annular Space or Vault Sensor. Mod I- U Annular Space or VRtilt Sensor. 'Modef- U Piping Sump /Trench el: U piping Sump / Trench Semor(R). ' Model: El rill Sump Sensoirfs) Moilel. U Fill Sump Sensor(s). Moilel: • Mechanical Line,LeRkbetectrit. Model: U Mechanical Line [,-,Rk Detector. Model: • Electronic Line Leak Detector. Model: U Electronic Une Leak Detector. Model: • Tank Overfill / Iligh-Level SenRni. Model: U Tnnk Overfill / lligh-Level Sensor. Model: • Other (specify equigment IZE and model in Section E oil I'age 2). P W 2). U Other (spcell y equipment typ! and model in Section E on_71 IXspenxerII):__) Dispenser 11): U KOH' c>r-)l 1.! U Shear Vnive(q). U Shear Vnlve(s). E3 Dia ser Containment Float s) and Chnin(s). U Uia neer Containment Floats l and Chain(s). Dispenser 1W. & J:' � . - I I Dispenser ID: - -2 V- L__ • Dispenser Containment Scrisor(s). odr, 1: e )01 Model_ U Dispenser Containment Sensor(s). Model: 3 • Shear Valve(s). U Silent Valve(s). L) Dispenser Containment Float s) and Chain(s). U Dispenser Containment Float sj and ChainW.,. Dialpenser ID: Dispenser ID: - Ll Dispenser Containment Senqor(s). Model: 11 Dispenser Containment Sensor(s). Model: E3 Shear Valve(s). U Shear VRIVC(R). L]Dist)enser Containment Float(s) and Chain(s). U Dispenser Containment Floats) and Chain 8). *If the facility contains more tanks or dispensers, copy this form. include information for every tank and dispenser at the facility. C. Certification - I cerary that the e(luirinwrif Idenflned lot fill% document waq Inspecteirl/serviced Its accordance with the usainitillacturers' guidelines. Attached to this Certification is information (e.g. numuracturere' checklists) necessary to verify that this Inforsantim b correct and a Plot Plan Rhowing the layout or monitoring equiptuent. For any equip niftent capable of generating aitch reports, I have also attached a copy or the report; (check alf Mal, applv)! U syq1ent Ret -tip U �)arm hl�!jr7 report Technician Name (print)- Siplinillir: . D; Jr " teel' Ccrtificnfion No.:-vit 11i f, - No,: :( Testing Company Ntime: -,7' ('hone No.�'P_Of --) 9 0 PHRe 1 Of 1 03MI