COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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fforbaA.-I 1, - `r r MAY 2 3 2003 a (IUAL17'1.7r.MN(�� FirAr)I%7r(ill()fINI)7i1NKN�17'Al;ri')I?I)�1BIER.47FS' ENVIRONMENT HEAtT Post Office Bot 36 71torwon, lit. V5686 (209) 794- 7I.VIP94-0112 Site Address: _-- J 2�; c. r I -I � ►, � I-� ('fly: �10�j Zip: Facility C'trntncl person: / ('imtnrt Phime Ni+. ( 1 Mnkr/Mmlrl ►►f Mnnitrning Svslrm, tMYi+�e °L / Q , � d'a if. lnveltlrrl-y of F41111pnie111 'Urstell/Cel-lilie•d Greek the appropriate boxes to Indicate specific eui li n►ent Instierted/ser vlred: Tank ID: V) -f r; f 'Tank I1 t: O In -Tank Unoging Probe. Madel: U ln-Tnnk Onuging 11rohr. - -^ Model: ❑ Annular Space. or Vault Senmor. Mndrl: 1_k) U Amrnlnt Spare or Vank Sensnr. Model: U Piping Sump / Trench Srnsor(R). M"'Irl: L 6=.42 2/" U Piping Sump / T►r►rch Sensor(s). Model: U fill Sump Sensr►r(t). Mndrl' U Dill S►nn11 Sensra(s). Mndrl: U Mechanical Line Ienk Drtrrim. Madel: U htrrhnnicnl l.h►c l e:nk Drievior. Mntlel:- ❑ Electronic Line Leak Detectnr, Model. U Pleceronic Line Leak Detectt►r. Model: O Tank Overfill / Ifigh-level Senttb. Model:. U Tnuk Overfill / I ligh-level Sensnr. Model- ❑ Other (specify ui ment type and model in Section G em Page 2). U Other (specify ui ment type and model in Section E oe Page 2). Tank iD- _ ~Madel. 'Tank IM E3 In -Tank Gauging Probe. _ U In -Tank Clanging Probe. _ Model: _ ❑ Annular Space or Vault Sensor. Mrxlel• U Anmdnr Space. or Vault Sensor. Model. ❑ Piping Sump 1 Trench Sensor(s). Model: U Piping Sump /'Trench Sensnr(s). Model: ❑ fill Sunup Sensor(s). Mtxlel• . U fill Sump Sensrn(s). Madel; _ ❑ Mechanical Line Leak Defector. Modrl: U Mrchnnica) Line.. beak Defector. Model: ❑ Electronic Line Leak Detector. Model: U Electronic Line LCRk Detector. _ Model: O Tank Overfill / Ifigh-Level Sensor. Madel: U 'Tank Overfill /I ligh-I evel SenRor. Model: ❑Other (specify ui ment I= and model in Section U on page 2). U Other (specify equipment anent t and model in Section E on Pae 2). Dispenser iD: / DIRpenser ID: r U DiRpenRrr Containment Srnsm(s). Madel' U DIRIWoRer ('nnlninnrrinl Sensm(s). Model: ❑ Shear Valve(a). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chnin(s). U Dispenser Containntenl Iloat(s) and Chain(s). Dispenser 11): _._ .. Dispenser ID: _ O Dispenser Contninment Sensor(s). Modri: ___.. U Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). U Sbenr Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). U Disprnser Containment iluat s and Chain(s). Dispenser 1D: _ _ _ _ _ ... _ , Dispenser ID: ' O Dispenser Containment Sensor(s). Model: __. __. _. _ . U Dispenser Coninionient Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(R). LJDispenser Containment Float(s) and Chain(s). U Dispenser Containment Moats and Chain(s). It ane incrtny comnins rams tanks or mspenseis. copy this ham. b►clude infonnntion far every lank and dirpenner at the facility, C. Ceriifienti(m -1 cerilfy that the egnlPnrrnt (rlrnUfleel It, Ihls dovmrnt was hoperled/Orrviced In accordance with the mamdiat:turers' guidelines. Attached M this Certification is Information (e.g. manufacturers' checklists) necessary to verify that this Ilifonmetion Is correct and a Plot Plan Rhowing the layout of ninnilnring equipn►ent. For any equlpnient capable of generating nich reports, I have also attached a copy of the report; (rherk all that apply): U S,yRtenr Ret -1111 U lorl� h 1 ry relu,r 'fechnicino Nanrr (print): �Y ��P ,t7. )�i► lM t- 6 tii1!nnnnc: ` / Certification No.: F>' 7 % 4) a - Q1;4? i I .ivewu- Nn,: �oC-r-- PnRr I for 3 03/01 f11onl1nrinR System (:ertifdrntion