COMPLIANCE INFO_2004-2008 - Laserfiche WebLink

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.lueneral i ormation Facility Name: Bldg. No.: Address: (0 4 _City: -Cz�' -i-nt.1 Facility Contact Person: _ �Ot�l 1 �� gyp: 9 Contact Phone No.: a� oq t�t� , ((�� ..Make/Model of Monitoring System: \1 D { -0 --::2 ( Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check tffihe neeroerinte boxes to indicates ecific cc ui "lent ins ected/serviced: Tank ID: Tank ID: >tL kfirla-Tank Gauging Probe. Model: Tank Gauging Probe. ir[inlet Space or Vault Sensor. Model: - _ Model: i,I° 11ri / Trench Sensor(s). Model: a Annular Space or Vault Sensor. Model: t l Sump P )' S 'Piping Sump / Trench Senso s . �.' ❑fll Sttmp Sensor(s). Model: ❑ Fill Sump Sensor(s). �) Model: d ❑ Meelaiiicatl Line Leak Detector. Model: ❑ Mechanical Line Model: 1 Leak Detector. Model: _ �iElectronic Line Leak Detector. Model: _�1 'Electronic Line Leak Detector. ❑ Tshk Overfill / High -Level Sensor. Model: Model: RIZE==: Cl Otlte (' eci ui "lent a and model in Section E on Pa e 2 ❑ Tank Overfill / High -Level Sensor. Model• i*k❑ Other (s ! i "lent a and model in Section E on Pae 2). T ID" Tank ID: lit Ir ik Gauging Probe. Model: —ii—_ CA ❑ In -Tank Gduging Probe. Annular Space or Vault Sensor. Model: ` Model: ❑ Annular Spaces or Vault Sensor. .Model: Piping Sump /Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ FiU Sump Sensor(s). Model: ❑ FU Sump Sensor(s). Ci Mechanical Line Leak Detector. Model: ❑Mechanical Line Model: Electronic Line Leak Detector. Model: l� 1 1 .q Leak Detector. _ Model: ❑ 'rank Overfill / High -Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: 13 PIP - .Others ui men[ a and model in Section E on Pa e 2 , Tank Overfill /High -Level Sensor. Model: -3 ) Other (s eci ui �t d1d )t 13 �j and model in Section E on Page 2). Dispenses ID: 3 user Containment Sensor(s). Model' �I p Shear Velve(s). 13 spenser Containment Sensor(s). Model: p(j Cl DIs user Containment Float(s) and Chain(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: _ �j 7 % � Dispenser ID: 4 ,ispenser Containment Sensor(s). Model: — --- ,cl 9 Dispenser Contaimiient Senso s . Shear Valve(s). ear Va1ve(s). i) Model: C.! D ser Containment Flont(s) and Chain(s). eDis) r enser Containment Float(s) and Chain(s). per m: —G1 'Containment Sensor(s). Model: E f D ' er iD; CS 7 hfs 1 P1 ?�spenser Containment Sensor(s). $itearalvc(e). 9'Shear Valve(s). Model: "er Containment Float(s) and Chain(s). 0 is'Penser Containment Floats) and Chain(s). 3 .cif the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility, �. 6ttification - I certify that the equipment identified in this document was inspected/serviced to accordance with gtttt[elines. Attached to this trertiflcation is information (e g, manufacturers' checklists n the manufacturers'ormonIs etltseef nt d a Plot Plan showing the layout of momtorin c ) arY verify that this tnfatmafion Is g' q pment: For any eq [hent capable of generating attached si copy of the report; (check al! that apply): g such reports, I have also . ystem set-up his ry report Technician Name (print): / i r0 Signature:. h R", CertiticationNo.: IZES License. No.:LAT z 077 L # C�WJ