COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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tsiag.lVo.: Site Address: 162 /' I.t) /la ✓fit dBW o g- � �i �,v City: ,✓'!j Zip: Facility Contact Person: Contact Phone No.: ( 101j.- _M lo of Monitoring System: E t '` Date of Testing/Servicing: 7 / 19 /4 B. Inventory of Equipment Tested/Certified Check the aDDronrinte hnxe_c to indie•ofa an—m— no..i.....e..t a...... -- Tank : -Tank Gauging Probe. alar Space or Vault Sensor. iping Sump / Trench Sensor(s). ❑ Fil�mp Sensor(s). echanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (soecifv eauinment tune And Model: 7-..._ Model"' Model Model: Model: Model: Model: model in Section E on Page 2). Tank ID: ❑ 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 (specify equipment type and model in Section E on Page 21 ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID:�_ ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). El -Dispenser Containment Floats) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and 0 Tank ID: j b L" 1`�, 8 -Iii -Tank Gauging Probe. Model: It Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: C70410405 ❑ Fill -Sump Sensor(s). Model: echanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank `5 X. i -Tank Gauging Probe. ®'lnnular Space Vault Model: or Sensor. iping Sump / Trench Sensor(s). Model: 6.1" Model: Q 00 0!0 ❑Fill p Sensor(s). Model: echanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui irtent =e and model in Section E on Pae 2). Dispenser ID: -,;; _1_/ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). P. 'C. Dispenser ID: _ ' 247=_ Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). V11 - Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: *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; (cheek all that apply): ❑ System set-up ❑ Alarm histery report Technician Name (print): Al %-2 A) P "4 41f(L_ Signatule: Certification No.: License No.: Monitoring System Certification