COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

Home Browse Search

YQUALI7YTESTING OF UNDIRGROUND 7ANKSATAFFORDABLERATES' Information Name: l') 794-0102 FAX 7r.. / Bldg. No.:__ Site Address: 2 i City: gip; 95 Facility Contact Person: Contact Phone No.: L7-07 ) yL 3 -- q / !'¢ Make/Model of Monitoring System: IJ C) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/service Taa ID: `��7 cmc' `7 In -Tank Gauging Probe. Model: A G, O'� Tank ID: ❑-Tank Gaugin e, Model: ❑ nular Spacer Va t Sensor. oAel: ❑ Pt ing Sum -rich ensor(s). Mod 1: ❑ F 1 Sump S sor(s). Mod ❑ hanic ne Leak etector. Mode ❑ EI troni ne Leak De ctor. Model. ❑ Tan erfill / High -Lev `L.S sor. Model: ❑ Other (specify equipment type and model in Section E on D�is�er ID: 1 {r' 2 —spenser Containment Sr)_ Model: u `-5 � Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Tank ID: K t n> 4.-r nulaz Space or Vault Sensor. Model: F 15 U Piping Sump / Trench Sensor(s). Model: ❑ F1 Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: -,K- ❑ 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: ❑-Tank Gaugin e, Model: ❑ nular Spacer Va t Sensor. oAel: ❑ Pt ing Sum -rich ensor(s). Mod 1: ❑ F 1 Sump S sor(s). Mod ❑ hanic ne Leak etector. Mode ❑ EI troni ne Leak De ctor. Model. ❑ Tan erfill / High -Lev `L.S sor. Model: ❑ Other (specify equipment type and model in Section E on D�is�er ID: 1 {r' 2 —spenser Containment Sr)_ Model: u `-5 � Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Tank ID: K t n> 4.-r ,EP-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 1 g Piping Sump / Trench Sensor(s). Model: u t� ❑ ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: rX 13 Electronic Line Leak Detector. _ Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tapk ID: f) i ESE L. Zlf�-Tank Gauging Probe. Model: Space or Vault Sensor. 14Rpular Model: �N 14 iping Sump / Trench Sensor(s). Model: 13 -.Fill. Sump Sensor(s). Model: C1 Mechanical Line Leak Detector. Model: X-1 VD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment typd and model in Section E on Paee 2). Dispenser ID: ❑ Di penser Containment Sensor(s). 13Sh Valve(s). 13Di eraser Containment Finnt(e) AT enser ID: Dispe�ser ID: ispenser Containment Senso s). Model: to trs ❑ Dis nser Co tainmen Zat(Osind ). M 1: P ear Valve(s). ❑ Sh V (s).s nser Containment Float(s) and Chain(s). ❑ Dispenser Containment Chain(s). Dispenser ID: ❑ ispens ❑ ear -Valve Dispenser ID: ❑ Disnensm-C and Chaim _—R] Dispenser Containment Float(s) and Model: *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' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring, went: For any meet capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alarm history report Technician Name (print): F_ Signature: Certification No.: I 1015License'. Monitoring System Certification