COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

Home Browse Search

M r AUG 20 ,�N t t OrrENVIRONMENT N QUALITY TESTING 0FUNDE-RGROUND7ANKSATAEFORDABLERA MIT/SERVI Post Oce Box 36 Thornton, eat'. 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: Bldg. No.: Site Address: 1 8_til.- kt to 130 V City: c A Zip: Contact Phone No.: ' Facility Contact Person: P � rr�� (' ) Make/Model of Monitoring System: CJ E� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the ageroeriate boxes to indicate ecific aqui menti ected/serviced: Tank ID: I--- Tank ID: ❑ In -Tank Gauging Probe. Model: 7'Cr- ❑ In -Tank Gauging Probe. Model: /1117 7 ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 5 PL! 7717 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: P V 5 ❑ 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 =e and model in Section E on Pae 2). ❑ Other (s eci ui ment a and model in Section E on Pa a 2). Tank ID: Tank ID: ❑ 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(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 a and model in Section E on Pa a 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). y� ❑ Shear Valve(s). ❑ Dis enser 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). ❑ 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). *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 ofmonitoring equipment: For any equipment capable of generating such reports, I have also attached i copy of the report; (eheck all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Signature: Certification No.: License. No.: _ Page 1 of 3 Monitoring System Certification 0