COMPLIANCE INFO_2005-2018 - Laserfiche WebLink

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Facility Contact Person: Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snerifir ...,.,:r,.. t Tank Model: ,;Tank Gauging Probe. Mod��,P AWlar Space or Vault Sensor. Mod ip_ mg Sump /Trench Sensor(s). Model: _2 P 5inp Sensor(s). Model M, Mechanical Lane Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (sped equipment pe and model in Section E on Page 2) Tank ID: ❑ In -Tank Gauging Probe. ❑ 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 (specify equipment pe and model in Section E on Paee 2)_ Dispenser ID• 1 ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Dispenser ID• ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Cnntninment Flnattal —A Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model: Model: Model: utuisgenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form bldg. No.: ® T ^ —fie Zip: Contact Phone No.: ( ) Date of Testing/Servicing: 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 (specify equipment t3w 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 (specify equipment type and model in Section E on Paee 2)_ Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains 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 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 histery report Technician Name (print): 1-1 Ct tification No.: _ Monitoring System Certification Signator:, _ License No.: