COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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Site Address: F't.._T07015 lag. IN a.: City: % .r'' Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: t �C, /_o ® Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: , / c r. `, Tank ID: 1,e Z-- - ❑ In -Tank Gauging Probe. Model: (zii 0® ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: '7-`2--2'3& 0 -4° 20 ❑ Annular Space or Vault Sensor. Model: -7 ` ,4 0 ❑ Piping Sump / Trench Sensor(s). Model: %42 4 3' �_U - 2'4P v ❑ Piping Sump / Trench Sensor(s). Model: -7 � . ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 (s eci ui ment a and model in Section -E on Page 2). ❑ Other (s eci ui ment type and model in Section E on Page 2). nED:ED:• l%i S ) / Tank •In -Tank Gauging Probe. Model: a� LlIn-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:F� "` `� ( IQLLI ❑Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: `7fWF a 13Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 (s eci ui ment type and model in Section E on Page 2). ❑ Other (seeciLt a ui ment type and model in Section E on Pae 2). Dispenser ID: ) 77. / °� I)/- � / Dispenser ID: / ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). v ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). /j Y 11 ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 7 f R-- : , Jam°- Dispenser ID: / / ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). YW Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). I ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this foam 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 inforination 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 history report Technician Namerint . � AJ r 1 ') / (P )' Signatui , — - Certification No.:�License. No.: ~+ Page 1 of 3 03/01 Monitoring System Certification,