COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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brag. iso.: Site Address: ai�i 4 n ty� TJ r— City: a ® Gy zip:.q6 Facility Contact Person: 1—r2Contact Phone No.: ( )3 (� &:: 0 `r, Make/Model of Monitoring System: 0dM d 1 )"2a ey Date of Testing/Servicing: -? / % i / O " B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sneciiic enninmPnt Gnannrtni��o..; . Tank ID: e Tank ID: l? f,_ J® ❑ In -Tank Gauging Probe. Model: 11� &W ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model % Annular Space or Vault Sensor. Mod : S O A7 13Piping Sump / Trench Sensor(s). Model: _ .S C ❑ Piping Sump / Trench Sensor(s). _ Model: .. Sc 191 5 ❑ 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 a ui ment a and model in Section E on Pae 2). ❑ Other (s eci equipment a and model in Section E on Page 2). Tank ID: Tank ED: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: E3 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 (s2eciLy Equipment Lyge and model in Section E on Page 2). ❑ Other (specify equipment a and model in Section E on Pa a 2). Dispenser ID: j, `7' Dispenser ID: jr& 14 ❑ 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: ! 5ae Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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). ❑Dis enser Containment Float(s) and Chain(s). p ❑ 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 PIan 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): /;," MOW Si natme:Z14.4. Certification No.: �`2r�7f�f License. No.: Monitoring System Certification