COMPLIANCE INFO_2004-2012 - Laserfiche WebLink

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Facility Contact Person: Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snerine T�annkk" _ ? C)d4 L"J"In-T k Gauging Probe. ular Space or Vault Sensor. Piping Sump / Trench Sensor(s). ❑ Fij!j5ump Sensor(s). Ol'ITecbanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (seecifj equipment type and Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector: ❑ Electronic Line Leak Detector. ❑ Tank Overfill/ High -Level Sensor. ❑ Other (sp equipment type and ; Dispenser ID: jL';k_ 13 - ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: — —< ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑Dispenser Containnent Float(s) and Model: Ma -P Model 4 DOeO7 Model: 4� a-- _=D Model: Model: Model: Model: model in Section E on Page 2). Model: Model: Model: Model: Model: Model: Model: nodel in Section E on Page 2). Model: Chain(s). Model: Model: Bldg. No.: Zip: _ Date of Testing/Servicing: `j / L / Tank I t L cn,�". t -Tank Gauging Probe. Model: f%7 car ' '!Zt— 13—)G alar Space or Vault Sensor. 0 ''1?iping Sump / Trench Sensor(s). Model•_4¢� Q --/a Model: rr- 13 F' ump Sensor(s). Model: LITMechanical Line Leak Detector. Model: T, !) ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui ment LYRe and model in Section E on Page 2). Tank ID• V r 6 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 1 � r1 Tr -'E ❑ Piping Sump / Trench Sensor(s). Model: �Q ❑ Fill S mp Sensor(s). U'rvechanical Model: Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui ment type and model in Section E on Page 2). Dispenser ID: Ll Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Floats) and Chain(s).' Dispenser ID: ❑ 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 ense C r on atnment Floats) and Cham(s). W 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 verffy that this information is correct and a Plot Plan showing the layout ofmonitoring 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 Nannie (print): Ld Certification No.: i % C� (� License No.: Monitoring System Certification