COMPLIANCE INFO_2003-2008 - Laserfiche WebLink

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114W40RING SYSTET-01 CERTIFT�_"�9;' ' � C ' E For ("Se BY,Lll,/ru-iseliclioils fI'ilhiit/he Slalc (?/'('(11i10'1'17io =I"11110111.C'iled: C'hnplcr G.7, Hettlllr ('o(le; C'hcr/ler l(, Dirisiun 3, Tile 13, C(11l f)r•rrin Ere c?¢4, q ,)IIS This form must be used to document testing and servicing of monitoring equipment. A separate c 'ti �� r port must lie prepared for each monitoring system control panel by the technician�vho performs the work. A copy of th e IV7A�'�°fil7lviclecl I() the tank system owner/opeiatgr. The owner/operator must subnuf!a copy of this form to the local 1('Fiy Tsysteins within 30 clays of test date. A. General Z7;_ n Facility Name: ,�/�'�G �^// ��T • Bldg.No.: Site Address: AL/f/C- 1� City: -T'dG,RG71 Zip: gs,2o 2 Facility Contact Person: Contact/ Contact Phone No.: (2) Make/Model of Monitoring System: Date of Testing*Servicing: 111/48 B. Inventory of Equipment Tested/Certified Check theapproeriate boxes to indicate secilic ec ui ment ins ected/serviced: Tank ID: 77 Cr7 Tank ID: JN In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: & Annular Space or Vault Sensor. Model: ®5 Cl Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: NLS ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sens01"(s)• Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leal:Detector. Model: FW•/ D ❑ 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 E on Page 2). ❑ Other(specify e ui ment type and model in Section E on Page 2). Tank ID: ( ®G."T Tank ID: A In-Tank Gauging Probe, Model: 4(7 ❑ 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: 99&V Z CO ❑ 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 E on Pa e 2). ❑ Other(specify equipment ty a and model i Section E on Page 2). Dispenser ID: I Y2 Dispenser ID: 4LDispenser Containment Sensor(s). Model: U LS ❑ Dispenser Containment Sensor(s). Model: lRShear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-fDispenser ID: a Dispenser Containment Sensor(s). Model: K I'S ❑ Dispenser Containment Sensor(s). Model: RL Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID:. A Dispenser Containment Sensor(s). Model: (ALS ❑ 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of/the report;(check all!ha/apply'): 19 Syste t u Alarm history report Technician Name(print): f�� V ,rata Signature: Certification No.: ,// 3 License.No.: L .-SQA '3/to-7 a LD T' Testing Company Name: Phone Site Address: f5// 4"Ir/G 4 14F Date of Testing/Servicing: S l re/0 g _ Page 1 of 3 - 03/01 Monitoring System Certification A Results of Testing/Servicing