COMPLIANCE INFO_2003-2008 - Laserfiche WebLink

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ADD a Uc QUALITY TESTING OF UNDERGROUND 7ANKSATAFFOR '.I F Z®Q� . Post Office Box 36 Thornton, Cat. 95686 (209) 794---! `92i, FST ; General Information Facility Name: ( � tC 1 Site Address: q511j� City Iric- ve Bldg.: zip: Facility Contact Person: l.� Contact P o.: oq '471'7q Make/Model of Monitoring System: I �� D rt rTesting!Servicing: 0/15 / os B. Inventory of Equipment Tested/Certified Check the appE2priate boxes to indicate ecific a ui rentinspected/serviced: T ID: G Ta ID: f 0#_,7-r -Tank Gan .ging Probe. Model: -Tank Gauging Pro Model:_ M alar Space or Vault Sensor. Model:_15? C: Annular Space or Vault Sensor. Model: -r-'>1 —t S Piping Sump/Trench Sensor(s). Model:_6P U Piping Sump/TrenchSensor(s). Model: :7� . tl1,S ElFill 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-Lev Sensor- Model: ❑ Other(s eci!x!2ui rnent a and model in Section E on Pae 2). ❑ Other(specify equipment and model in Section E on Pae 2). Tank ID• Tank ID• ❑ In-Tank Gauging Prob . Model: E3 In-Tank-Gauging Probe. Mod"e�' L3Annular Space or Van] Sensor. ModeL•! ❑ iiular Space or Vault Sensor. .'Mode}� 13 Piping, amp/Trench ensor(s). Model: a Piping Sum /Trench Sensor( M l: ❑ Fill Sump Sensor(s). odel: ❑ Fill Sump ensor(s). M el: ❑ Mcchanical Line Detector Model: ❑ Mechanic Line tor. Mo 1•_ f 1❑electronic Line Leak etec Model: ❑ Electronic>�in Detector. Model: 51/Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Levet Sensor- Mo e ❑ Other(s ui ment=e and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Pa a 2). Dispenser ID: I 'i Z Dispenser ID: Dispenser Containment Sensor(s). Model: ISI u 1-6 ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). ❑ Dis enser Containment Floats)and Chain(s). Dispenser ID: 3M Dispenser ID: D}spenser Containment Sensor(s). Model: U ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). 13Dispenser Containment Float(s)and Chain(s). Dis er ID: Dispenser ID: ispenser Containment Sensor(s). Model: 1-1 11&4) ❑ 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 eq meat: For any equi went capable of getwrating such reports,I have also attached a copy of the report;(check all that apply): Irsystern set-up Alarm histery report Technician Name(print): •iJ�E q1VV1VVVD Signatuic: Certification No.: 1/06 License_No.: Monitoring System Certification