COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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u � ti; Jrr , MW 'QUALITY TESTING OF UNDERGROUND 7ANKSATArT0RD,ABLE RATES' Post Office Box 36 Thornton, Cay 95686 (209) 794-0102 FAX 794-0112 General Pity Name: `h) —�-;� mjt �� v� a � Site Address: 3 3 LJ ' Bldg. No.: -/0(/% - �Q City: -- Zip: S 5�0,S " Facility Contact Person: X42 (J Contact Phone No.: Make/Model of Monitoring System: �,'r l�,f} i�� ,yl�J - Date of Testing/Servicing• /-2 / Al B. Inventory of Equipment Tested/Certified _Check the appropriate boxes to indicate specific equipment inspected/service Tank ID: L l ti, g El Piping Sump / Trench Sensor(s). ❑ In -Tank Gauging Probe. Model: v. 131 ❑ Annular Space or Vault Sensor. Model: _> `/ ❑ Piping Sump / Trench Sensor(s). Model: `743 0-- ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: Other (specify equipment pe and model in Section E on Page 21 Tank ID: I?/hoc,,' ElIn-TankGauging Probe. Model: ! > a_ / El Annular Space or Vault Sensor. Model: x=11 :5 ; El Piping Sump / Trench Sensor(s). Model: �9-Y - ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: 13 Other (s eci ui mea and model in Section E on Pa e Dispenser ID: l ?_ - -0 f- ", El Dispenser Containment Sensor(s). Model: 13 Shear Valve(s). El Dispenser Containment Float(s) and Chain(: Disp rnsee ID: ❑ Dispenser Containment Sensor(s). Model: L3 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: . El Shear Valve(s). ❑Dispenser Contain^lent Float(s) and Chain(sl *If the facility co„eains more tanks or dispensers, copy this form. C. Tank ID: C% 1 � ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment a and model in IED: 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: _ ❑ Electronic Line Leak Detector. Model: _ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: _ / i r /13 Dispenser Containment Sensor(s). Model: / ❑ Shear Valve(s). - ❑ Dispenser Containment Float(s) and Chains) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ElShear Valve(s). -' ❑ Dispenser Containment Float(s) and Chains) Section E on P Include information for every tank and dispenser at the facility. 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 ❑ Aurin history report rn E on 0 �j r, Technician Name (print): � �/ �t 4-117 t-» Signatuic: Certification No.: License No.: C7� Monitoring System Certification ��