COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

Home Browse Search

c _ L4 1 AMU `UN 0 1, 2005 f frrrba__"Q1 R' 1'RFAM'fLD%THEALT1 t QUALITY TESTING OF UNDERGROUND TANKSATAFF& W Post O Office Thornton, Ca 95686 ) � J� u�i� cour�(Y112 .ff' (209 744 2 ; HEALTH D General Information Facility Name: 4Gp,W a-- r fly ` ( Bldg.No.: Site Address:_330.41 W # g1 ar s1, City: 2,- I 67, `1 Zip: 'I oto 111 Facility Contact Person: h GLb Contact Phone No.: 5} g Lo 0 Make/Model of Monitoring System:--,ae J r S Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate Meeffic a ui ment ins ected/serviced: r D: V I--- Tank ID: ank Gauging Probe. Model: ! ❑ In-Tank Gauging Probe. Model: !W—5 � ular Space or Vault Sensor. Model:')'"Al W4>0" ❑ Annular Space or Vault Sensor. Model: ng Sump/Trench Sensor(s). Model:74J43 R-- ❑ Piping Sump/Trench Sensor(s). Model: "moo Sump Sensor(s). Model: I ❑ Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: /-">--Zl ❑ Mechanical Line Leak Detector. Model: f ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecify 2SWEment!12e and model in Section E on P!Se 2). ❑ Other(s eci Equipment ty22 and model in Section E on P2&e 2). Tank ID: 96 k D Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: $ ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 5.7r 0 ❑ 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 equipment a and model in Section E on Pae 2). ❑ Other(sgecillui ment a and model in Section E on Page 2). 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). " ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senser(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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). Y`'`" ❑ 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;(check all that apply): ❑System set-up ❑Alarm histcry report Technician Name(print): �Y�t` 0� �� G Signafwe: Certification No.: 19 d License.No.: Monitoring System Certification