COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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�Af f QUALITY TESTING 01-, UNDERGROUND TANKS AT AFFORDABLE RATES' Post Oce Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Infoqti - e Facility Name: / 0 P il I W Bldg. No.: Site Address: ® 2- 5114 gkT6Y-M01 14 t2 r, City: 11 Zip: Facility Contact Person: JTO Contact Phone No.: PQ 9)_ _ Make/Model of Monitoring System: -e ta i� � 0)0 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate ecific ni meat Inspected/serviced: Tank ID: ZZ P Tank ID: ❑ 1b -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Gf— Annular Space or Vault Sensor. Model: f ❑ Annular Space or Vault Sensor. Model:_�cp ❑ Piping Sump / Trench Sensor(s). Model: -a 5C, ❑ 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 (s eci ui ment =e and model in Section E on Pa a 2). ❑ Other (s eci equiLnLent and model in Section E on Pae 2). Tank ID: Tank ID• ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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 (sEecitj r,3uipment type and model in Section E on P e 2). ❑ Other (s eci a ui ment type and model in Section E on Pae 2). Dispenser IDDispenser ID: aAGAt ❑ Diger Containment Sensor(s). Model: ❑ Dis enser Containment Sensor(s). Model: UYShe yalve(s). 2ispen�,e lve(s). is enser Containment Float(s) and Chain(s). Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: he alve(s). ❑ Shear Valve(s). W-15i'spenser 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 Containrnent 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 correct and a Plot Plan showing the layout ofmonitoring 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 a Technician Name (print): k,04 tP 1 vp W6 Signature: Certification No.: ('7 `? License. No.: "" i` Page 1 of 3 Tl l Monitor F Monitoring Svstem Certification