COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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,'.T TP 9 DEC 13 21 Crr F 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLi& �,�1ci, T Hf`= Post Office Box 36 Thornton, Ca 95686 209 794-0102 FAX J ` ( ) 794-0112 'General Information (^Nil l� C'/lf} Z_/ i� p � t l/`Lam t f hJ Facility Name: 3 3Ot� n �.�," Bldg. No.:� Site Address: �,{ City:-slU',.�C,�h Zip: clS Facility Contact Person: 6 zbi4 Contact Phone No.: (yE3f.�_) Make/Model of Monitoring System: Date of Testing/Servicing: le72 B. Inventory of Equipment Tested/Certified Check thea roriate boxes to indicate eciric a ui ment inspected/service Fan: �' u S k Gauging Probe. Model• T 5 N0 ar Space or Vault Sensor. Model: '7? *2j — Z/ -,10 Sump / Trench Sensor(s). Model:;: ump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Page 2). Tank ID: 7:7 e -, ,P f ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 79�3Fr� —ao�T ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specia ui ment type and model in Section E on Pa a 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(sj. Dispenser ID: 1:�e ❑ 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). ❑Dis enser Containment Float(s) and Chain(s). Tank ID: ,% i4 I, ❑ In -Tank Gauging Probe. Model: OLQ, p ❑ Annular Space or Vault Sensor. Model: '7243 C ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: -Ll Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump 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: ?-- l ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: / / f / ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ry S Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser 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 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 a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm histery report Technician Name (print):..../- id o ;� k�7 t -r, Sign3tw Certification No.: 0 License No.: Monitoring System Certification