COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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f farba--T C$� rlvf AUG QUALITY TESTING OF UNDERGROUND TANKS AT AFFORDABLE OF ZU Post Office Box 36 Thornton, Car: 95686 (209) 794-0102 FAX *4"0�� ti Y (General InformationI Facility Name: by ftj-1 Site Address: 16 S 6 ea �,,j -rP- V Facility Contact Person: Bldg. No.: City: ( o c-t,6-'F_C�, Zip: Contact Phone No.: ( � 9 )_ 116 z - /� a Sa— Make/Model of Monitoring System: �I�1�%i Date of Testing/Servicing: a / Z /_ B. Inventory of Equipment Tested/Certified Check the appropriate hnxea to :,.aim to —o. m TI Gauging Probe. Model: �1�7 ,eank pular Space or Vault Sensor. Model: Va Piping Sump / Trench Sensor(s). Model: ❑ 11 Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:)=/C - ( V ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment type and model in Section E on Page 2). Tapk ID: 1 ( (9G7 In -Tank Gauging Probe. Model: !rj ❑nular Space or Vault Sensor. Model: Id,pi Sump / Trench Sensor(s). Model: El Sump Sensor(s). Model: ' Mechanical Line Leak Detector. Model: X-1 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a quipment type and model in Section E on Page 2). Dispenser ID: ❑QPrS,Penser Containment Sensor(s). ear Valve(s). Model: +tf Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑mss enser Containment Sensor(s). Valve(s). Model: Z!,Oar Dis enser Containment Float(s) and Chain(s). 1 Dispenser ID: ./' 1i ❑ Dispenser Containmebt Sensor(s):'_ ensor(s)' Mod 1: 13 Shear V�lve(s). ❑Dis enser i:_ontam lent Floats) and Chain(s)." *If the facility contains more tanks or dispensers, copy this form Include ii Tank ID: ❑ In -Tank Gauging Prob . Model: ❑ Annular space or Vaul Sensor. Model: ❑ Piping Sump /Trench nsor(s). Modeh, ❑ Fill Sump Sensor(s). Model: F Mechanical Line Leak tector. Model: --� Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Se sor. Model: ❑ Piping Sy�ifip / Trench Sens r(s). Model: ❑ Fill Surtip Sensor(s). ❑ Mechanical Line Leak Dete tor. Model: Mod 1" tronic Line Leak Detector. Model: k Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Se sor. Model: ❑ Piping Sy�ifip / Trench Sens r(s). Model: ❑ Fill Surtip Sensor(s). ❑ Mechanical Line Leak Dete tor. Model: Mod 1" ❑ E&e tronic Line Leak Detecto del: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify equipment type and model in Containment Sensor(5). Model: nser Containment Float(s) 4nd rID: e ser Containment Sensor(S). Valve(s). `a iser Containment Float(sand r ID: Val Model: 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 .manufacturers' the kiists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring a '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 Ala his cry report Technician Name (print): kl__) -- 1M-0 Signatui:.: Certification No.: / License No.: T on Eon Monitoring System Certification