COMPLIANCE INFO_2006-2012 - Laserfiche WebLink

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nlug.1W.; Site o. - Site Address: 1 t.-.: _ Cityy P Zip: 4152W5 Facility Contact Person: A Contact Phone No.: (_) Make/Model of Monitoring System:i:L'T® `T I Date of Testing/Servicing: AL79-1/4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/service Tapk ID: D WL- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ In -Tank Gauging Probe. Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: 4'5 '645- 41 L® 'ping Sump / Trench Sensor(s). Model: 1� ` 3 Fill Sump Sensor(s). Model: -- ❑ Mechanical Line Leak Detector. Model: Tank ID• ❑ Electronic Line Leak Detector. Model: . ❑ Tank Overfill / High -Level Sensor. Model: ❑ Piping Sump/ Trench Sensor(s). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill/ High -Level Sensor. El Other (specify equipment tvae .and r Model: Model: Model: Model: Model: Model: Model: iodel in Section E on Page 2) Tank ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (!2equipmentpe and model in Section E on Page 2) Tank ID• manufacturers' checklists) necessary to verify that this information is Cl In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ FillSump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: ❑ Dispenser Containment-Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). enser Containment Floats) and Chain(s). ❑ Dis enser Containment Floats) and Chain(s). ris enser ID: ispenser Containment Sensor(s). Model:❑Dispenser Dispenser ID: Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this forall 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 monitoring eq ' menL For any eq ' ent capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alarm history report Technician Name (print): ��4nlf. Ail, Certification No.: // F-9 Monitoring System Certification Signatur License. No.: _112 (7 'a Q i - L ( -r