COMPLIANCE INFO_2000-2009 - Laserfiche WebLink

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i Uiug. iu.: Site Address: ✓2 302 r� C .� City: gip. !' ` 2lw _ Facility Contact Person: _lei? Contact Phone No.: )9 qGq35B Make/Model of Monitoring System: VCS-��(' - - S o Date of Testing/Servicing: /A3/ D B. Inventory of Equipment Tested/Certified Check the aunronriate boxes to indicate saecific eauinment inspect 0 In -Tank Gauging Probe. Model: M GAC, Annular Space or Vault Sensor. Model: 79 U 1 ❑ Piping Sump /Trench Sensor(s). Model: 7 z a ❑ Fill Sump Sensor(s). Model- "Mechanical Line Leak Detector. Model. L, 0-6 ❑ Electronic Line Leak Detector. -D Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ In-i'agingProbe Model: ❑ Anular Spa Vault Sensor. Model: ❑ Piping Sump / T ensor(s). Model: ❑ Fill Sump Sensor(s). ❑ Mechanical Lane Leak ❑ Electronic Line ❑ Tank Ove gh-L ❑ Other edfv eonium� tor. Model: Sensor. Model: rpe and model in Section E on 11 r W1 RIn -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: LO ❑ FiIl Sump Sensor(s). Model: JBi Mechanical Line Leak Detector. Model: IF t ❑ Electronic Lane Leak Detector., Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ In- 'uging Probe. ❑ Anular Sp Vault Sensor. ❑ Piping Sump/ Trenc ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak ❑ Electronic Lane Cl Tank Overti gh-L ❑ Other ( fv Pnninm .Model: Sensor. Model: _ e and model in Section Dispenser ID: r ', Dispenses ID: 4 Dispenser Containment Sensor(s). Model: % ' Dispenser Containment Sensor(s). Model: 20P Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dens ID: £ Dispenser ID: et .Cy Dispenser Containment Sensor(s). Model: _ 'spenser Con ta nment Sensor(s). Model: —2 f Shear Valve(s). bear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 4 1 U Dispenser ID: 4 TE - Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). Cl 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'lpertif►catiou is information (e g. manufacturers' checklists) necessary to verify that this information is -correct and a Plot Plan showing the layout of ia►onitorin6 uipment For any a ment capable of generating such reports, I have also attached n copy of the lt that report; (check aft apply); System set-up Alarm histo, y report Technician Name (print): L 1 V tMm n Signature. Certification No.: License. No.: 92- iN3 CC # 52-49115 -- LX I Monitoring System Certification