COMPLIANCE INFO_2007-2011 - Laserfiche WebLink

Home Browse Search

__ ___ '� ro v t✓® e 9. a Cw 4"-0 R2 "V D! L A tT Te 'QUALITY TESTING OF UNDL'RGROFIND 7 KSAT AFFORDABLE RATES' 16 2nd Street halt, CA 95632 (209) �i #14 4-0ll6. ' JUN 2 5 2009 General Information Facility Name: _ � i �' �` _ENVIRONMENT HEAL] g.No.:�` Site Address: q 2 ° Ch '- V� City: ` r }T/SERVICE - Zip: Facility Contact Person: : }. kj Contact Phone No.: C.Z Make/Model of Monitoring System N d'.. `t :i m "„ i0 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appLopriate boxes to indicates eeific 9ui ment' ected/serviced PTank ID: / Tank ID; In-Tank Gauging Probe. Model: 't C) gf Tank Gauging Probe. Model: / tj Annular Space or Vault Sensor. Model: 2 a Annular Space or.Vault Sensor. Model:_ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model _ ❑ ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model i t i r Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: (3 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(sj2ecifv a ui ment type and model in Section E on PMS 2). ❑ Others eci a ui ment a and model in Section E on Pa a 2). Tank ID: T TE Tank ED: -T_ t id° Tank Gauging Probe. Model fie"0 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model ,f 4 Annular Space or Vault Sensor. Model: > ❑ Piping Sump/Trench Sensor(s). Model: 11 Piping Sump/Trench Sensor(s). Model: ill Sump Sensor(s). Model E3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:'i r", GrMechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ® Other(sp equipment type and model in Section E on Page 2). ® other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: 0 In-Tank'Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Lane Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Cl Tank Overfill/High-Level Sensor, Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecify equipment t e and model in Section E on Pa a 2). 13 Other(s eci equipment a and model in Section E on Pae 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 Mechanical bine Leak Detector. Model: El Mechanical Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ® Tank Overfill/High-Level Sensor. Model: ❑ Other(sgecia a ui ment Df a and model in Section fi on Page 2). 1,0 Other(s eci a ui ment a and model in Section.E on jPage ). *LF 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 of m' of itoring equipment; For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): 13 System set-np ❑Alarm history report Technician Name(print): 1 x KG ci Signature Certification No.: License.N`.:DTTL- 08- 1_/b Fo TCC 52 2'j 3 q Wonitoring System Certification