COMPLIANCE INFO_2003-2008 - Laserfiche WebLink

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&1-%f f arba--TePt y QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLE RATES' Post Oce Box 36 Thornton, Cay 95686 (209) 794-0102 FAX 794-0112 General Info ation f Facility Name: �2 G' / Bldg.No.: � Site Address: V��I Oy w i i lel Avp City: Facility Contact Person: Contact Phone No.: ( V D-1�) Make/Model of Monitoring System: bll o tl / Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the:agEroeriate boxes to indicate 2ecific equipment ins ected/serviced: Tank ID: - Tank ID: '®Z 3—In-Tank Gauging Probe. Model: Z22 lly_ i ❑ In-Tank Gauging Probe. Model: �t 7 5-Annular Space or Vault Sensor. Model: 7_5 (SLE-1 1; ❑ Annular Space or Vault Sensor. Model: r' Z�-Z ❑"Piping Sump/Trench Sensor(s). Model: 7-S 7'2 car. . ❑ Piping Sump/Trench Sensor(s). Model: r-S P t,, A 5 ❑ Fill rnp Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U-Me-chanical 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(s eci ui ment a and model in Section E on Pae 2). ❑ Other(s eci ui ment=e and model in Section E on Pae 2). Tank ID: Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: x ❑ 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(s eci ui ment type and model in Section E on Pa a 2). ❑ Other(=62 a ui ment type and model in Section E on PaLe 2). Dispenser ID: / �-�Z— Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: T'S 0"-Ll L 15 ❑ 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: _� 14_`-1 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 1-S E-- - A,_-�r> ❑ 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). [Zispenser ispenser ID: �i ff'L Dispenser ID: Dispenser Containment Sensor(s). Model: "S(1�° S ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 11 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 a copy of the report;(check all that apply): ❑System set-up ❑Alarm histery report Technician Name(print): �� Signatui::: 'a` Certification No.:_ th � �7 �° �� License. No.: ',7 Page 1 of 3 03/01 Monitoring System Certification