COMPLIANCE INFO_1992-2005 - Laserfiche WebLink

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- - . - -- rsiag. no.: Site Address: i2 S• `� a I City: 5f O Q is 1 Zip: s Facility Contact Person: Contact Phone No.: ( .9 a '7) `/ i 5 - 20 Make/Model of Monitoring System: 1 f1, _Q -rL,'5 ` 5E:P Date of Testing/Servicing: b / LZ / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecific enninment incnert ZZ '& t OC- i Tank ID: ank Gauging Probe. Model: ✓►? Gr ❑ in -Tank Gauging P e. Model: _ -77- Annular Space or Vault Sensor. Model: -71V,300 -le ❑ Annular Space o /Vault Sen r. Model: ng Sump /Trench Sensor(s). Model: i❑ iping Sump / tench Senso s). Model: Sump Sensor(s). Model ❑ ill Sump S sor(s). Mode _ hanical Line Leak Detector. Model: ---"� ❑ e 'Sun. m Line Leak Detecto Mo L ` tronic Line Leak Detector. Model: _V Lt_�j ❑ lec nic Line Leak Detector. del: Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: r (s eci ui ment a and model in Section E on Pae 2). ❑ Other (s ec' ui ment and model in Section E on PaLe 2). : Tank ID• ank,Gaugn Probe. Model: ❑ In -Tank Gauging'Piobe. Model: ❑ Annular Space o Vault Sensor. Model: ❑ Annular Spdce or Vail t Sensor. Model:— _ ❑ Pip} g Sump/ T rich Sensor(s). Model/ ❑Piping Sump /Trench ensor(s). Mode ❑ 1iAl Sump Sensor( ). M el: ❑ Fill Surfip Sensor(s). Mo ❑ l echanical Line ak Detector. el: ❑ Mechanical Line Leak etector. el: Electronic Line Le etector Model: Wthr 6onic Line Leak De tor. odel: Tank Overfill/ High -Leer. Model: Overfill / High -Levet Model: ❑ Other (s eci ui ment a and model in Section E on Pa a 2). (s eci a ui ment a and model in Section E on Page 2). Dispenser ID: DiLear ID: spenser Containment Sensor(s). Model: ❑ s on me ensor(s Model: _ Shear Valve(s). ❑ V ve(s).❑ Dis enser Containment Fioat(s) and Chain(s). ❑ser Containment Float(s) and ain(s). Dis eraser ID: Dispenser ID: ❑ Djspenser Containment Sensor(s). Model: T ❑ Di penser Containm rat Sensor(s). el: �7 Shear Valve(s). ❑ Sh Valv ❑ Dispenser Containment Float(s) and Chain(s). ❑ Disg ontainment s) and Chain(s). Dispenser ID,__ Dispgnser ID: ❑ hear alve(s). `W - ❑ Sh V e(s). ❑Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) anLChnjs):.� *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 ( g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring pment. For any eq ' ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alarm istery report Technician Name (print): I KA Vv4b Signature Certification No.: _ License. o.: Monitoring System Certification 0