COMPLIANCE INFO 2002-2010 - Laserfiche WebLink

Home Browse Search

J V UALITY 7Eb77A'G Oh-UNDERGROUND 7ANKSATAEFOR r�� r- Post ©ice Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 NOV 2 200; General information ENVIRONMENT Facility Name: CaMl I F Lr Site Address: I" c f L� { ,. , , �. _ a .r T S `W 'Fo.: ( -_ �M City ° ° zip:. t / Facility Contact Person: Ltc e r Contact Phone No.: (�) Make/Madel of Monitoring System: cx l i 4��' `^ _ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the approgriate boxes to indicates edlic eq ui ment ins ected/serviced: Tank ID: 2 tir Tank ID: TZ-) 1 -r' El In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: L-Annular Space or Vault Sensor. Model: k5 —3 ❑ Annular Space or Vault Sensor. Model:Wril 3 ping Sump f Trench Sensor(s). Model: k5— CI Piping Sump/Trench Sensor(s). Model: —3 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; CiI'l�echanica]Line Leak Detector, Model: 57?iU/�/J IJ 1�'Vechanical 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 equipment t e and model in Section E on Pae 2). ❑ Other(s eci a ui merit_type and mode]in Section E on Pa a 2). Tank ID: Tank ID: D 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(&), Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 4 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector_ Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: EDnse i equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). : Dispenser ID: ontainment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: e(s). ❑ Shear Valve(s). ontainment Float(s)and Chain(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model: G Shear Valve(s). ❑ Shear Valve(s). EJ 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), Mo6el: 0 Shear Valve(s). ❑ Shear Valve(s). I❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility cmitains 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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(cheek all that apply): ❑System set-up ❑Alarm history report // J 1 f _\ Technician Name(print):-t�`l /V iY�!i sr A Signature: r✓ � -� 'r J bD p 1 v Certification No.: License No.: Page]of 3 0-3/01Monitoring System Certification