COMPLIANCE INFO_1986-2006 - Laserfiche WebLink

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�.. ' .. i Ask 1 'QUALITYTESTING OF UNDERGROUND TANKSATAFFORDABLERATES' 416 2nd Street Gads, CA 95632 (209) 744-0112 FAX 744-0116 S _ General Information r J FacilityName: L-, _' 1 ( �` s Bldg.No.: . Site Address: 6 f"' r `®". j kv Aa City: FacilityContact Person:_ Zip. Contact Phone No.:� - � Make/Model of Monitoring System: ew z r Date of Testing/Servicing: / - B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecific equipment iected/serviced: Tank T,2 /1P Tank ID: Gauging Probe. Model:_ Gl ❑ In-Tank Gauging Probe. Model:_ Space or Vault Sensor. Model 5 Ll Annular Space or VaultSensor. Model: ipmg Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: El Tank OverFll/High-Level Sensor. Model: ❑ Other(s eci ui ment a and model in Section E on P e 2). ❑ Other(Vecifv a ui ment ty2e and model in'gection E on Pa 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑'In-Tank Gauging Probe. Model: ❑ Annular Spam or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. .Model: ❑ Piping Sump/Trench Sensor(s). Model: [3 Piping Sump/Trench Sensor(s). Model: (3 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Levet Sensor. Model: ❑ Other(s ui ment qge and model in KdonEn P e 2). ❑ Other(s eci ui ment a and model in Section E on Pae 2). Dispenser ID: Dispenses ID: ElDispenser Containment Sensor(s). Model: 13Dispenser Containment Sensor(s). Model: 13 Shear Valve(s). ❑ Shear Valve(s). ElDis enser 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). Model: 13 Shear Valve(s). El Shear Valve(s). . ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser 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). Ci 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'Cerdfication is information (e.g. manufacturers' checklists) necessary to verify that this information is -correct and a Plot Plan showing the layout of inonitoring Equipment: For any-equipment capable of generating such reports,I have also attached a copy of the report;(check aQ that apply): ❑System setup ❑Alarm history report Technician Name(print): P , Q Signature: w fl Certification No.: b 4 Q License,No.: — I CC 5249115�- I.l q Air....: .....-.�[+....t..� n.._�:r...,.�..._