COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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Site Address: 2-512 o% -C fl k City: i_ Zip: Facility Contact Person: "C Contact Phone No.: )..t4j0,3 LJJ J Make/Model of Monitoring System: T IJ t i OW e Date of Testing/Servicing: Q9 /_I I/ ®/o B. Inventory of Equipment Tested/Certified Check the aonronriate boxes to indicate snecific enninmenf incn—t Tank ID: `i" � I oc_r Model: t/1CA t In -Tank Gauging Probe. Model: A 0 Annular Space or Vault Sensor. Model: L J Piping Sump / Trench Sensor(s). Model: �? . ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 'FX -I \1 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 2)_ Tank ID: Model: t/1CA t ❑ 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: 6 Electronic Line Leak Detector. Model: b Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in ection E on Tank ID: 1-11 trIn-Tank Gauging Probe. Model: t/1CA t b Annular Space or Vault Sensor. Model: 1. 21 Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: eebanical Line Leak Detector. Model: F - ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s2ecify a ui ment ty2e and model in Section E on PaLe 2). Tapk ID: Dispenser Containment Sensor(s). Model:❑ t In -Tank Gauging Probe. Model: Vr, Annular Space or Vault Sensor. Model: 1 ) S OrPiping Sump / Trench Sensor(s). Model: t )t ❑ FillSump Sensor(s). Model: ,l Mechanical Line Leak Detector. Model: 'F --I VT) ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecia ui ment a and model in Section E on Pae 2). Dispenser ID: _ 1 Z Dispensei ID: 3 4 Jd Dispenser Containment Sensor(s). Model: Shear Valve(s). Ut S Cd' Dispenser Containment Sensor(s). Model: ,J ❑ Dispenser Containment Float(s) and Chain(s). Zf Shear Valve(s). ❑Dis user 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). ❑ Dis enser Containment Float(s) and Chain(s). Di'enser Containment Float(s) and Chain(s). Dispenser ID: ispenser ID: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Sensor(s). Model:❑ t is enser Containment F1oat(s) and Chain(s). Shear Valve(s). Dis ser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, c py this form. Include information for every tank and dispenser at the fac`li• . C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this 1perttiication is information (e g. manufacturers, checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring 'pment: For any a ui ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ystem set-up arm histo . r report Technician Name (print): ZAAI t Mme-, , Signature: Certification No.: �l �� License. � , z UT 0-77 y # a - I GI G Monitoring System Certification