COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

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May 19 05 11 : 01a Aff da-Test (208)M,794-0112 p. 2 X. ® �T ;.m T t farba.- QUAU7-y T (.)I•'vNUr.,RGRO[J1VD 7AAFK.SATArFVIrDA81,r.RAM, Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 General Wormation Facility Name: raai r?�•P r All Fs i'-��G�� --- Bldg.No.: y Site Address: 30"1�, Le_e•0r A22 µPi- y• City: f r~ �A zip: a5LJ Facility Contact Person: S h h a..b Contact Phone No.:1, � 1 9 5 I-agip.0 � Make/Model of Monitoring System: Date of Testing/Servicing: /jQ�?7 B. Inventory of Equipment Tested/Certified Check the appropriatu boxes to iadlcatetic ui mime In a serviced- Tank ID: `�'U �-- Tank IID: ❑ In-Tank Gauging Probe. Model: ® In-Tank Gauging Pinkie. Model:!" WWnnudar Space or Vault Sensor. Nextel: H ti"N0� �// ® Annular Space or Vault Sensor. Model. *- W-9--ping Sump/Trench Scnsor(s). Model:7'",T$ !'"4R— i ❑ Piping Sump/Trench Sonsor(s). Model: ❑ Fill Sump Scnxcx(x)• Model: 0 Mill Sump Saasor(s). Model: 1rAcc 2 haniusl Linc Leak Detector. Model: I 1 A1,,2 Q Mechanical Line Irak Detector. Model: ❑ Electronic Line Leak Detector. Madel: ❑ Electronic Line Look Detector. Model: ❑Tank Overfill/High-bevel Sensor. Model: ❑Tank Overfill/High-Levcl Sensor. Model' _-- t7 Other(specify ui nY and nu)dcl in Section E on Pa 2). Q Other(. i!X ESuirment t and mtxW in Section E on),age 2). Tank W: 6( Q Tank IID: U In-Tank Gauging Prof. Madel: /J'r"'" U In-Tank Gauging Prohe. Model: ❑Annular Space or Vault Senior. Model: o' "►" ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 39-Or-: ❑ Piping Sump/Trench Semxor(x). Model: ❑ Fill Sump Sensor(-). Model: __-- ❑Fill Sump Seanm r<(a). Model: U Mechanical Lithe Leak Detector. Model: � ' �'; °: ❑Mcchwnical Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill I High-Level Sensor. Model: U Other(s ai ui t and model in Section E on Page 2). ❑ Other(s ui trent and modal in Section E on Pa 2). Dispenser ID: Dispenser ID- 13 Dispcn%er Containment Sensof(s). Memo!: ❑ Dispenser Containment Sonmvr(s). Model: C1 Shear Valve(s). LI Shear Valve(%). ❑ Dispenser Containment Roos)and Chain(s). !✓`o ; ❑ Dis user Containment Float(x)and anin(s). Mpenser ID: _ Imo: Q Dispenser Containment Sensor(s). Model- ❑ Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). ❑ Dispeow Containment Float(x)and Chain(s). ' ❑ Dis nser Containment Floats and Chain(s). Dispenser IID: Ilisprau:cr ID: ❑ Dispenser Containment Scsnsor(s), Model: U Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). 13Shear Valve(s). ❑Di% nsw Containurnt Flont(s)and Chain(s). 4 °°� ❑ Disegnser,Containrnent Floc s)and Chnin(s)• *If the facility contains colo tanks or dispensers.copy this form. Include information for every tank and dixpenxer at the facility. C. Certification.I certify that the equipment iduatillcd in this document was inspected/serviced in accordance with the nuamftecturers' guidelineb. Attached to this Certification bi information(e.&manufactarch7:' checklists) necessary to verify that this infumination is correct and a Plot Plan showing the layowl of monitoring equipmeoL For any etluipm mt capable of geLterating such reports,I have also attached a copy of the report;(c/sick cell dint ripply): Cl System set-up ❑Alarm history report Technician Name(print): Certification No.: !License.No.: --- Monitoring System CertiCcation