COMPLIANCE INFO_2002-2015 - Laserfiche WebLink

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i ---- - - . _- - -- • - niug. tvu. Site Address: g�0 i[!y Lb vjkW_ Sar__2,�Mftil�/U_� City: �Toc-k7-oty Zip: �i O Facility Contact Person: KA L_ /� Contact Phone No.: Make/Model of Monitoring System: &CF1 7D-BtLdt_ Date of Testing/Servicing: B. Inventory of Equipment Tested/Cerdfied Check the appropriate boxes to indicate specific eauipment insuected/serviced: = l C7 C-'-7 Tank ID: i ®L — ank Gauging Probe. Model: Jlrb-Tank Gauging Probe. Model: PaD* ular Space or Vault Sensor. Model: ®� . !ular Space or Vault Sensor. Model: ng Sump /Trench Sensor(s). Model: 3 Z- Piping Sump / Trench Sensor(s). Model: 5 Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s).Model: hanical Line Leak Detector. Model: Cl Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: J,IElectronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: her (s eci ui ment a and model in Section E on Pae 2). ❑ Other (s ' e ui ment and model in Section E on Pae 2). ID: ® C--" T Tank ID: VnJaank Gauging Probe. Model: M 1 ❑ In -Tank Gauging Probe. Model:pular Space or Vault Sensor. Model:?n❑ Annular Space or Vault Sensor. Model:ing Sump / Trench Sensor(s). Model: �'! ❑ Piping Sump / Trench Sensor(s). Model:l Sump Sensor(s). Model: ❑ Fill. Sump Sensor(s). Model: ❑ Pechanical Line Lealc Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/ High -Level Sensor. Model: CI Tank Overfill / High -Level Sensor. Model: ❑ Other (speciLl equipment a and model in Section E on P e 2). ther (s eci ui ment a and model in Se tion D"D' penser ID: 1 04— 7- enser ID: '71— 8 Dispenser Containment Sensor(s). Model: 2?ispenser Containment Sensor(s). Model: lisne6ser Shear Valve(s). hear Valve(s). 13Dis enser Containment Float(s) and Chain(s). Containment Float(s) and Chain(s). penser ID: Dispenser ID: AA Dispenser Containment Sensor(s). Model: 'Z 2 ❑ Dispenser Containment Sensor(s). Model: I Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser ConW—nm Floats) and Chain(s).�s ❑Dim cases Containment Float(s) and Chain(s). / penser ID: S4- Dispenser ED: UKL Dispenser Containment Sensor(s). Model: _ '3Z2- ❑ Dispenser Containment Sensor(s). Model: Ehear Valve(s). ❑ Shear VaIve(s). UDisgenser Containment Float(s) and Chain(s). f ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form Include informaation 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 (rertificafion is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout ofmonitoring' pment: For any,eqpUftent capable of generating such reports, I have also attached a copy of the report; (check ail that apply): System set-up AAlarm history report Technician Name (print): �94n1 f_ All, m ift2`r, Signatur Certification No.: License. No.: 4 'T111 I�Z3 `,Z% - (.,l.T Monitoring System Certification