COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

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PostOffice Box l Thornton, / 95686 1; Facility Name: Site Address: ° ® 1 Facility Contact Person: (20 9)794-0102 FAX 794-0112 Bldg. No.: City: ^_t t l"?C�j Zip: Contact Phone No • Make/Model of Monitoring System: _ , �� Date of Testing/Servicing:/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate rnerifir annin—t Tank ID: M it k "-Tank Gauging Probe. 5��nnular Space or Vault Sensor. Er Piping Sump /Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify ui ment type and Tank EN ' Lf ❑ 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 tvve and i Dispenser ID: ` Y --a—. ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Di2s enserr 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). and Model: Mk Model: "/� Model: 70,ft Model: Model: Model: Model: iodel in Section Model: r'/ f Model: N )I Model: Model: Model: Model: Model: iodel in Section E on Page 2). Model: Tank ID: DI -e ❑ 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: Cl, Other (specify equipment tyge and model in Tank ID: ❑ Dispenser Containment Sensor(s). ❑ 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 (sEecify equipment a and model in Dispenser ID: ❑ Dispenser Containment Sensor(s). Model:, ❑ Shear Valve(s). ❑ Dispenser Containment Rnnt(a) —A ('ha:../. Dispenser ID: L Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Chain(s). e ❑ Dispenser C!nntninm,-nt mnat(.N -q (•t...:..(. Model: *If the facility contains more tanks or dispensers, copy this Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: E Section E 0 information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was ins 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 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 histcry report P J Technician Name (print): i 4 L -k'+ 01 f Signatti Certification No.: License. No.:% Page 1 of 3 03/01 Monitoring System Certification