COMPLIANCE INFO_2000-2009 - Laserfiche WebLink

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: -If i 1 Zip: Contact Phone No (2UQ g z Fj —�j3 j f, 9 / 7 /OS Make/Model of Monitoring System: 'rW Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snnrifir em,in—t Tank ID: 6"7 Model: I� Gauging Probe. Model: A& f R�ITank nular Space or Vault Sensor. Model: ping Sump / Trench Sensor(s). Model: .d Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD i Gbo ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page ❑ I -Tank Gauging (robe. M� el: ❑ nular Space, . VauI Sensor. M del: ❑ Piping Sump /%T nch Sensor(s). del: ❑ ill Sump S s s). oriel: Mechanic Lin Leak Detect odel: Electr c Line De te r. odel: ❑ Overfill / ' - el Sensor. Mo ❑ Other (specify equipment type and model in Section E on ispenser ID: 1 iZ_. ,Dispenser Containment Sensor(s). Shear Valve(s). Dispenser Containment Float(s) and spenser ID:� � �( ,Dispenser Containment Sensor(s). Shear Valve(s). Dispenser Containment Float(s) and ipenser ID• S Dispenser Containment Sensor(s). Shear Valve(s). Model' Model: Model: ai ufilfispenser Containment Float(s) and Chain(s). *If the facility cotitains more tanks or dispensers, copy this form Tank Gauging Probe. Model: I� Annul Space or Vault Sensor. Model: 0(o ping Sump / Trench Sensor(s). Model: $ ?—' fill Sump Sensor(s). Model: 205 Mechanical Line Leak Detector. Model: `?If L -D Zo00 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: j? ( (-- S c � Tank Gauging Probe. SAnnular Space or Vault Sensor. 'U Piping Sump / Trench Sensor(s). ZFill Sump Sensor(s). Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (snecifv enninmPnt t%m —A Model: A Model: Model: 3 �z Model: 2b o Mode1:L1!t LD Model: Model: model in Section E on Page 2). Dispenser ID: { Dispenser Containment Sensor(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Z*per ID®®� Dispenser Containment Sensor(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Dis eraser ID: Dispenser Containment Sensor(s). Shear Valve(s). ❑ Dispenser Containment Hoat(s) and Model: Model: � Model: "z . 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 g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoringuipment: For an?I-brm ment capable of generating such reports, I have also attached a copy of the report; (check all that apply); ystetn set-up histery report Technician Name (print): Signatulia: -a-- Certification No.: /f License No.: Monitoring System Certification