COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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Site Address: l %r P •- IAS. at ave Facility Contact Person: M h r fA Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate soecific enuinment ingnectPaImrrvirn.i- �((qzip:Contact Phone No: )15 Z -331-10 Date of Testing/Servicing: -7 Z1 Tank ID: X 111( 6— Tank ID: In -Tank Gauging Probe. Model:- —�, _ ank Gauging Probe. Model: Lr'Annular Space or Vault Sensor. Model ti QAnnular Space or Vault Sensor. _ Model: E "iping Sump / Trench Sensor(s). Model- a. D/ R- aping Sump / Trench Sensor(s). Model: 000 0/0 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: D'Mechanical Line Leak Detector. Model: 1, Z2 n,94!2 ©-Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / IIigh-Level Sensor. Modes: ❑ Other (specify a ui ment type and model in Section E on P e 2). ❑ Other (s e ' e ui ment type and model in Section E on Pa 2). Tank ID: Tank ID: ❑ Io -Tank Gauging Probe. Model: U -In -Tank Gauging Probe. . Model : eweV2- ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). Model: Cd" Piping Sump / Trench Sensor(s). .Model: Model: WW 13 Fill Sump Sensor(s). Model: ❑ Fail Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: C' lAechanical Line Leak Detector. Model: 19e iLa PION&F ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ModeL• ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (spEEft equipment a and model in Section E on Page 2). ❑ Other ( eci equipment a and model in Section E on Pae 2). Dispenser ID: Dispenses• ID: �'�` 4/ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser 111 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ElShear Valve(s). ElShear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis nser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ ' enser 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 inspectediserviced in accordance' with the manufacturers' guidelines. Attached to this'Cerdfication is information (e.g. manufacturers' checklists) necessary to verify that this information is -correct and a Plot Pian showing the layout ofmonitoring equipment: For any.equipment capable of generating such reports, I have also attached n copy of the report; (check all that apply): ❑ System set-up ❑ Alarm histo r epos .. ----------- Technician . -- Technician Name (print): L.116_11 y't tM►m n Signature:62 -�- Certification No.: ? D License, No.: CC. 52.49 � 15 -- I t t Aonitoring System Certification