COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

Home Browse Search

rsiag. 1,4 o.: Site Address: DO a -kb_ ® ST City: GvTo Zip: Facility Contact Person: mc, Contact Phone No.:Z( -E`I Make/Model of Monitoring System: �&epe ?- 7 'il', 5cc> Date of Testing/Servicing: 3 /7,7LOG OG B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate specific a ui ment ected/serviced: T 0C__0 Tank ID: -Tank Gauging Probe. Model: ®r ❑ In -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: Zv ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: , J Mechanical Line Leak Detector. Model: ❑ 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 (sEeciLy equiRment a and model in Section E on 'Page 2). ❑ Other (specilla ui rent tyge and model in <ection E on Pae 2). Tan ®c ?' Tank ID: In -Tank Gauging Probe. Model: AdA&r 7, ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: 13fiF 11 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). -. _ Model: Mechanical Line Leak Detector. Model: ❑ 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 aa ui ment a and model in Section E on Pa a 2). ❑ Other (specify equipment a and model inction E on Page 2). Dispenser ID: 1 .7 Dispenser ID: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Di enser ID: 3 q 5 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 Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). f: *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 info-nmation is correct and a Plot Plan showing the layout of monitoring 'pment: For any a pment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alarm history report Technician Name (print): Zits'. Signatuie: Certification No.: Monitoring System Certification -moi 077 L -9 04-1-1 L, j