COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

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titog. No.: - Site Address: (C?.. °" City: -.41"'W, ( Facility Contact Person: Contact Phone No.: (,�`, r� ) �C"- 0 e? Make/Model of Monitoring System: ve' Date of Testing/Servicing: B. Inventory Inventory of Equipment Tested/Certified Check the aDuronriate hnYec to Tank ID: & 141- 13 In -Tank Gauging Probe. 42�_ lar Space or Vault Sensor. Piping Sump / Trench Sensor(s). ❑ FiRsump Sensor(s). echanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and Model: Model: - Model: ? 4Y 1f - .Pon Model: Model: S oOl Model: Model: lodel in Section E on Page 2). Tank ID: U i Y 13 In.:Tank Gauging Probe. Model: / EV -Annular Space or Vault Sensor. Model: 7 CP -'/j3 ❑ Piping Sump / Trench Sensor(s). Model: a ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: / ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(sl Dispenser ID: —� 1V /) ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Model: *If the facility cotitains more tanks or dispensers, copy this form 19 Tank ID: '5� ❑ In -T k Gauging Probe. Model: CL" Annular Space or Vault Sensor. Model: ° ®'Is ping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: W-Mec anical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (seecify equipment type and model in Section E on Page 2)_ Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other, (s eci a ui ment a and model in Section E on Pae 2). Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID:'- ` f 13 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s- Include information for every tank and dispenser at the facility. 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 histery report Technician Name (print): Si an a' � .. Certification No.: o Coc,License No.: Monitoring System Certification