COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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Dec 10 03 09:43a r LJ El P. Site A ldress: Bldg. No.:-± Z Baty:=c.yt iv .r.,r Zip: Faciiit /Contact Person: Contact Phone No.: (�`) Make/ 4odel of Monitoring System: G- I 1 lnr,� t -e u /rl (i Date of Testing/Servicing: l / / 18 " B. II .ventory of Equipment TesteWCertified Check t ie aro to boxes to indicate specific equipment insvedc'd/servie ed: Tank I ): -, ❑ la -T ink Gauging Probe. Model: _ is ry ® Tank ID: ,e 6-- ❑ In -Tank Gauging Probe. ❑ Ann liar Space or Vault Sensor. Model: 7G"� - y a 5 O Pipi :g Sump / Trench Sensor(s). Model: ❑ Anne Space or Vault Sensor. E3 Model: Val Model: 7 �•-i-riFsO - Al> a O Fill lu Sens mp or(s). Model: Piping Sump / Trench Sensor(s). Model: 7 ❑ Mec umicai Line Leak Detector. Model: O Fill Sump Sensor(s). ❑ Mechanical Line Irak Detector. Model: Model: ❑ Elec tunic lane Leak Detector. Model: O Tani Overfill / High -Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Othe r (s ecW !SuiLnient Wx and model in SectionE on Page 2). ❑ Tank Overfill / High -Levet Sensor. Model- ❑ Other (ui Tank 11is ment type and model in Section E on ❑ In -T ak Gauging Probe. Model: Q -01t ra ®Anne Space or Vault Sensor. -,— Tank ID• ❑ In -Tank Gauging Probe. Model: .lar Model: "WAP ❑ Pipir g Sump / Trench Sensor(s). Model: 13Annular Space or Vault Sensor. 13 Piping Sump / Trench Sensor(s). Model: Model: ❑ Fill ' ump Sensor(s). Model: ❑ Meel anical Line Leak Detector. Model• ❑ Fill Sump Sensor(s). Model: ❑ Elect tunic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 3 Tank Overfill/ High -Level Sensor. Model: ❑ Electronic Line Leak Detector. O Tank Overfill / High -Level Sensor. Model: Model ZI Otho went and model in Section •E on P e 2). "a ❑ Other ( e jemM= and model in Section E one 2). Utspens :r ID: . --� •� J;: 3 Dispt nser Containment Sensor(s). Model: Dispenser ID: .3 3 Shea: Valvc(s). ❑ Dispenser Containment Sensor(s). Model: • ] Dispe user Containment Floats and Chain R ❑ Shear Valve(s). ❑ Di r,ME= Containment Floal(sl and Chain(s)./r's? S )ispeos r ID: =• .K U ] hear user Containment Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). ] Shear Seat Valve(s). Model: ] Dispe aser Containment Flo s) and Chain(s). v . ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains I )ispeust r ID: 13 DispeShear tsar Containment Sensor(s).. Model: Dispenser ID: . 1 ] Shear Valve(s). O Dispenser Containment Sensor(s). Model: t lD➢span ter Containtnent Float(sj and Chain(s). ❑ Shear Valve(s). ° If the fa 75ity contains more tanks or dispensers, copy this form. Include information (3 Dispenser Containment Float s) and Chain(s). for every tank and dispenser at the facility '. Cel'tlflcation - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guid elinoes. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is Corr tct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attar bed a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report I echnici m Name (print): Signature: (ertiflca ion No.: License. No.: Page 1 of 3 03/01 A [ouitoa ng System Certification