COMPLIANCE INFO_1986-2006 - Laserfiche WebLink

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,w tow 1 DI t a r QUALITY TESTING OF UNDERGROUND TANKS AT AFFORDABLE RATES' Post Office Box 36 Thornton, Ccs 95686 (209) 794-0102 FAX 794-0112 ®. General Information Facility Name: 1 O" -I .- losp, Bldg.No.: Site Address: i 2 3 5 t.<.y V® .S' (r City: 1- ® Zip: -K4 V0 Facility Contact Person:— qA`/ Contact Phone No.: ( O� ) 3 - 76(6-7 ,y/ Make/Model of Monitoring System: .t'rD 5-7L,< i/1 Date of Testing/Servicing: _ / 2_84_!26 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecific equipment Inspected/serviced: Tank ID: V/ L Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: L-5-3 L] Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: L 5- El Piping Sump/Trench Sensor(s). Model: ❑ 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-Level Sensor. Model: ❑ Other(specify ui ment tKLe and model in Section E on Pae 2). ❑ Other(specify a ui anent a and model in Section E on Pae 2). 103 ank ID: Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: L3 L] Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: L] Piping Sump/Trench Sensor(s). Model: 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-Level Sensor. Model: [❑ Other(s eci ui rnent a and model in Section E on Pae 2). ❑ Other(s eci ui ment tyLe.and model in Section E on Pa a 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: 13Dispenser Containment Sensor(s). Model: Shear Valve(s). L3Shear Valve(s). Dis 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: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). [Dispenser ID: Dispenser ID:Dispenser Containment Sensor(s). Model: LiDispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s)and Chain(s). ❑ 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 Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eq ' menta For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm histery report Technician Name(print): ! Signattu : Certification No.:_ License.No.: W/ 4 Monitoring System Certification