COMPLIANCE INFO_2002-2015 - Laserfiche WebLink

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Facility Contact Person: i -r a ".5 `J Contact Phone No.: ( - ) 9°41 Make/Model of Monitoring System: _L4.5-300 V J1 Date of Testing/Servicing: ? / B. Inventory of Equipment Tested/Certified Check the anoroariate boxes to indicate specific ec uiament insuected/serviced: Tank ID: S 0 % Tank ID: le �, 1 _ ❑ In -Tank Gauging Probe. Model: 1'71 0 F ❑ In -Tank Gauging Probe. Model: kll 6e "� ❑ Annular Space or Vault Sensor. Model: '7 441 - -VO ❑ Annular Space or Vault Sensor. Model: `7 4W-4 `5 40 _J40 ❑ Piping Sump / Trench Sensor(s). Model: 44-1 VP' 13 Piping Sump / Trench Sensor(s). Model: 2fi� L4.N , y ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 2 echanical Line Leak Detector. Model: 9-lvlechanical Line Leak Detector. Model: CJ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Pae 2). ❑ Other (sgeciLi aqui ment a and model in Section E on Pae 2). Tank ID• Tank ID• ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui ment a and model in Section E on Page 2). ❑ Other (specify ui ment type and model in Section E on Pa a 2). Dispenser ID: /7t ` 6 e ( PL, '. F0 Dispenser ID: /fit" k ❑ Dispenser Containment Sensor(s). Model: _ - S ❑ Dispenser Containment Sensor(s). Model: -7 -,5`j3 -e-,,- ; Ofr ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. 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 (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 history report Technician Name (print): f 7 P 1, �W Signature: f Certification No.: f?License. No.: _ G� —11 Page 1 of 3 ATG Monitor Form Monitoring System Certification