COMPLIANCE INFO_2000-2005 - Laserfiche WebLink

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Facility Contact Person: Contact Phone No.: Zip: Make/Model of Monitoring System: 'F -r:) W ! 'T Date of Testing/Servicing: W k� 73 B. Inventory of Equipment Tested/Certified Check the,aeero riate boxes to indicate ecific equipment inspected/serviced: Tank ID: Z1, P Tank ID: 'k - ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: S ` ❑ Annular Space or Vault Sensor. Model: 5 V 40 1. ❑ Piping Sump / Trench Sensor(s). Model: % S ,3 6= ❑ Piping Sump / Trench Sensor(s). Model: `? " 3 -' ❑ 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 rent a and model in Section E on Pae 2). ❑ Other (s eci a ui ment a and model in Section E on Page 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 (specify ui rent and model in Section E on Page 2). ❑ Other (s eci equipment a and model in Section E on Page 2). Dispenser ID: .L— Dispenser ID: 0 '— ❑ Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: 40 C) ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: & (D Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 4. 47 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser 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). ❑Dispenser Containment 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' checidists) 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): �`f' rt/° l 1''7"7 o Certification No.: 62 z/ L Signatut:,: _ 044 License. No.: Page I of 3 03/01 Monitoring System Certification