COMPLIANCE INFO_2004-2015 - Laserfiche WebLink

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-niug: Site Address 3q 1r City: STyG�G7"® zip: f — — Facility Contact Person: Contact Phone No.: ) 9J`�� ' D b Make/Model of Monitoring System: A 1E-0 2-7 _rtS- 3 56 Date of Testing/Servicing: /? / 10-6 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to.indicate specific eauinment insner_tedlaerv1-1- Tan1c,JD: Z5 ` O -Er Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: ,7!'iping Sump / Trench Sensor(s). Model: 5,11 Sump Sensor(s). Model: �"echanical Line Leak Detector. Model: ff Lb Z000 ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Model: f ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 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 Tauk ID: _ `I 1 e> -an T k Ga Probe. e. Model: f Annular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model: 43'Fll Sump Sensor(s). .Mechanical Line Model: Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 13 Other (specify equipment type and model in Section E on Tank ID: _ Ih t E -S l- .E]'In-Tank Gauging Probe. ❑'ular Space or Vault Sensor. ping Sump / Trench Sensor(s). ll Sump Sensor(s). echanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and r. Model: M Aft Model• Model: Model: Model: e— Model: Model: iodel in Section E on DLDis r ID: - Dispenser ID: V I Containment Sensor(s). Model! ❑ Dispenser Containment Sensor(s). Model: j�Valve(s). ❑ Shear Valve(s). ❑ser Containment Float(s) and Chain(s).❑ Di eraser Containment Float(s) and Chain(: Di eraser ID: f `f Dispenser ID: Oispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: El Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). D' enser ID: Dispenser ID: Rf.Dtspenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 21 Shear Valve(s). ❑ Shear Valve(s). 1.91)ispenser Containment Float(s) and Chain(s). 1 ❑ Dis enser Containment Floats) 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 gertification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of m� ' 'onitoring pment: For any a ui went capable of generating such reports, I have also attached a copy of the report; (check all that apply):ystem set-up Alarm history report S Technician Name (print): Z�}„!� All, en ry,7n Signature:.. AUE' Certification No.: License. No.: _�� (! .<j Z jn � 3 C.,(,T CFU L Monitoring System Certification