COMPLIANCE INFO_2004-2015 - Laserfiche WebLink

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tsiag. No.: Site Address: 41 & e,ars A City:i' / zip: Facility Contact Person: puf Contact Phone No.: O Make/Model of Monitoring System:1/- Z 51 3 5-D Date of Testing/Servicing:��- S. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snerifir PaninmPnt i„.„P,.t TankJD: j-<," I, Dank Gauging Probe. Annular Space or Vault Sensor. �! ing Sump / Trench Sensor(s). (W'Ftlll~ Sump Sensor(s). mechanical Line Leak Detector. ❑ gpetronic Line Leak Detector. ank Overfill / High -Level Sensor. ❑ Other (specify equipment tvpe and: ❑ 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 (specify equipment type and i Model: A,;z 4e_._V_ / Model: 7"l3Ss-W —mss PE Model: D4s�'fu�TTD — Model: -.,_0 2� Model: �l Model: Model: Gi iodel in Section E on Page 2). Model: Model: Model: Model: Model: Model: Model: Section E on Tank ID• 1R 9 ❑ I Tank Gauging Probe. p�AAnn ular Space or Vault Sensor. I�!y,ing Sump / Trench Sensor(s). U -Fill Sump Sensor(s). anical Line Leak Detector. ❑ Electronic Line Leak Detector. Overfill / High -Level Sensor. ❑ Other (specify equipment type and Model: Model: '!!3 —6 { Model: Model: Model: o Model: Model: 1: e iodel in Section E on Page 2). Tank ID: 3 -5 --Tank Gauging Probe. Model: % ❑ Aqnular Space or Vault Sensor. Model: f I 5*TriS,mg Sump / Trench Sensor(s). Model: a p Sensor(s). Model: _V-6 ce Mechanical Line Leak Detector. Model: 5-0O25 ❑ El-eWonic Line Leak Detector. Model: Q'Taink Overfill / High -Level Sensor. Model: '1 ❑ Other (sped equipment type and model in Section E on Page 2). Dispenser ID: i )`-" _- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: zw"` ❑ 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). 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). L3Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model _2a ❑ Dispenser Containment Sensor(s). Madel: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 Certification is information (e.g. manufacturers' checklists) necessary to verify 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; (cheek all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): N� �`t�' 6l=�z 4 Signatui Certification No.: �%�' °�� License. No.: Monitoring System Certification