COMPLIANCE INFO_1985-2005 - Laserfiche WebLink

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QUALITYTESTING OF UNDERGROUND T'ANKSATAFFORDABLE ' '' 52005 Post®ice Box 36 Thornton, Com 95686 (209) 794- q l2 g `/4L�� PERr�I�T ISE VICES General Information Facility Name: QL4 Oakei- L_4P174.(— Site Address: b® I Z' SP(��.- �� Bldg.No.: City: ��Pk'�li �'.�"�.P zip: Facility Contact Person: Contact Phone No.:( ) Make/Model of Monitoring System: l .� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate ecific a ui 2 inspected/serviced: T k ID: 1 lrc� Tank ID: In-Tank Gauging Probe. Model: �� ❑ In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: l' ❑ kulaurace or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: ❑ p/Trench SenFill Sump Sensor(s). Mdel. l' Mechanical Line Leak Detector. Model: ❑ Sensor(§). Mode❑ Electronic Line Leak Detector. Model: ❑ trl L' ak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: L3 Tank❑ Electronic Line Leak Detector. Model: sor. Model: 13 Other(s eci a ui ment a and model in Section E on Page 2). ❑ OtherO(s Bifj ll/I ugh nt type Se and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. M el: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor('§). Mode. ❑ Fill Sump Sensor(s).,--" Model: Fing Sump/Trench Sensor(s). Mo❑ Fill S p Sensor(§). Model:❑ Mechanical L' er6eak Detector. Model: ❑ Mecham Line Le elector. Model: ❑ Electron ne Leak Detector. Model: I-LEI Electronic Li Detector. Model: ❑ Tank verfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci a ui ment a and model in Section E on Page 2). NO Other(s eci equipment a and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s).f Mode: ❑ Dispenser Containment Sensor(s). Model: ❑ ear Valve(s). ❑ Shear Valve ❑ s enser Containment Float(s)and Chain1s). ❑ Dis ens ont ment Float(s)and Chain(s). Disp user ID: s Dispe r ID: ❑ D spenser Containment Sehsor(s). Model ❑ spenser Contai ent Sensor(s). Model: ❑ Siear Valve(s). �'� Shear Valve(§). ❑ D Tenser Containmen Float(§)and Chain ). ❑ Dis enser Contai ent Float(s)and Chin s , Disposer ID. ) ❑ D spenser Con ment Sensor(§). Model: id2ispenser ID: ❑ S ar Valve ❑ Dispenser Containme Sensor(§ odel: El ens ontainrzient Float(§)and Chain(§). ❑ Shear Valve(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. . manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of moult oring eq ' ment For any equi men capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm histery report .01 Technician Name(print): 4 Sig natwc: _ Certification No.: T License No.:_Cot- Monitoring V — System Certification