COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

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t. l'F 'QUALITY TESTING OF UNDERGROUND TANKS'ATAFFOItD. � V ( 0 41 f 2nd Street Galt, CA 95632 (209) 744-0112 o II ENVIRONIMEE T HEALTH `� General Information PERMIT/SERVICES Facility Name: V.)c,.i 1b© RxA 4_, Tye_� Bldg.No.: . Site Address: S 03;e2. W 2.42,r'" 10 0 City: + Zip: Facility Contact Person: Contact Phone No.: �® Make/Model of Monitoring System: T L Date of Testing/Servicing: 06/�q B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific Sq uiment ins ected/serviced: Tank ID: '14 1 Tank ID: ❑ Zn ank Gauging Probe. Model �'P . El In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7,S1,00 47'dT, ❑ Annular Space or Vault Sensor. Model: B-Pliping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: L4 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O'Vgechanical Line Leak Detector. Model: r2 La.L7 ❑ 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 ui ment a and model in Section E on Page 2). ❑ Other(82EEa(8ae ui ment a and model in Section E on Pae 2). Tank ED: Tank ID:__ r-?d -F, ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model ± ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. .Model: h Awrro 4,r ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FillIl Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: i_7 Electronic Line Leak Detector. Model: ❑ Electronic Lure Leak Detector. Model: C1 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ ther(sngj equipment a and model in Section E on P e 2). C3 Other( eci a ui rat a and model in Section E on Pae 2). b4e'user ID• DisgenseT ID ❑ ispenser Containment Sensor(s). Model: .e ),„'5 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis eraser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID:. ❑ Dispenser Containment Sensor(s). Model: L4 k5 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Di enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Ploat(s)and Chain(s). Dispenser ED: ? `4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model•_ It, L,52 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). 1 ❑ Dis enser Containment Floats)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'lPertiiication is information (e g, manufacturers' checklists) necessary to verify 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 ri copy of the report;(check all that apply), ❑System set-up ❑Alarm history re t Technician Name(print):_�.tJ�P 'eyY1 p Signature: J Certification No.: License.No.: — CC 52.'-!9115 - u$ Monitoring System Certification