COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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L B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment/devices that wereinspected/tested/serviced: List and identify all tanks and dispensers. Do not include equip rraentldevices which were not inspected/tested/serviced Tank ID: Regular Unleaded Gasoline Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: PDWF ❑ Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: LS -ASC ❑ 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 equipment type and model in Section D on Page 4). ❑ Other (specify equipment type and model in Section D on Page 4). Tank ID: Supreme Unleaded Gasoline Tank ID: ❑ In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: PDWF ❑ Annular Space or Vault Sensor. Model: 1] Piping Sump / Trench Sensor(s). Model: LS -ASC ❑ 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: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section D on Page 4). ❑ Other (specify equipment type and model in Section D on Page 4). 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 equipment type and model in Section D on Page 4). ❑ Other (specify equipment type and model in Section D on Page 4). Dispenser ID: Hoses #1 & #2 Dispenser ID: Dispenser Containment Leak Detection Method: Dispenser Containment Leak Detection Method: ❑x Mechanical Shut -Off (float and chain actuated shear valve). ❑ Mechanical Shut -Off (float and chain actuated shear valve). ❑ Sensor(s) Connected To Console Model: ❑ Sensor(s) Connected To Console Model: Stand Alone Liquid Sensor(s) Make: ❑ Stand Alone Liquid Sensor(s) Make: Model: Model: Dispenser ID: Hoses #3 & #4 bispenser ID: Dispenser Containment Leak Detection Method: Dispenser Containment Leak Detection Method: ® Mechanical Shut -Off (float and chain actuated shear valve). E3 Mechanical Shut -Off (float and chain actuated shear valve). ❑ Sensor(s) Connected To Console Model: ❑ Sensor(s) Connected To Console Model: Stand Alone Liquid Sensor(s) Make: - ❑ Stand Alone Liquid Sensor(s) Make: Model: Model: Dispenser ID: Dispenser ID: Dispenser Containment Leak Detection Method: Dispenser Containment Leak Detection Method: ❑ Mechanical Shut -Off (float and chain actuated shear valve). ❑ Mechanical Shut -Off (float and chain actuated shear valve). ❑ Sensor(s) Connected To Console Model: ❑ Sensor(s) Connected To Console Model: ❑ Stand Alone Liquid Sensor(s) Make: ❑ Stand Alone Liquid Sensor(s) Make: Model: Model: Dispenser ID: Dispenser ID: Dispenser Containment Leak Detection Method: Dispenser Containment Leak Detection Method: ❑ Mechanical Shut -Off (float and chain actuated shear valve). ❑ Mechanical Shut -Off (float and chain actuated shear valve). ❑ Sensor(s) Connected To Console Model: ❑ Sensor(s) Connected To Console Model: ❑ Stand Alone Liquid Sensor(s) Make:: ❑ Stand Alone Liquid Sensor(s) Make: Model: Model: If the facility contains more tanks or dispensers, attach another copy of this form.