COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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City: Lo t> t Zip: Facility Contact Person: Contact Phone No. Make/Model of Monitoring System: Date of Testing/Servicing: / B. Inventory of Equipment Tested/Certifled Check the appropriate boxes to indicate specific a ui menti ected/serviced: T ID: Tank ID: Tank Gauging Probe. Model: r❑ 13 In -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: A " g L ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: �5 A-S�-• ❑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 (speciLf 2qui2ment a and model in Section E on Pae 2). ❑ Other ( eciui ment a and model in Section E on Pae 2). T ID: Tank ID: In -Tank Gauging Probe. Model: M. ❑ In -Tank Gauging Probe. Model: ❑ nular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: _ L L- ❑ 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: .and ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment a model in Section E on P e 2). ❑ Other ( eci ui ment jZge and model in Section E on Pae 2). Dispenser ID: r Dispenser ID: ❑ spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: X.! yShear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Cieispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: car Valve(s). PDis2enser ❑ Shear Valve(s). 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 'ment capable of generating such reports, I have also correct and a Plot Plan showing the layout of monitoring a 'pment: For anyeXA attached a copy of the report; (check all that System apply): set-upI istor re t Technician Name (print): _ ZnAIF All, Certification No.: Monitoring System Certification Signatur License. No.: --`-_;- .<j Zjd �Z `1 i - t_,,_T 071L T;t ot4