COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

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W rrn-) S'j_ jAffrrrbzv-,'T.e,'Rt , • . r ENVIRONMENTAL �2 QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLE RATES` t /; t r t t r �; r� / rK-1111:11/ r� �, 'General Information.1 ilitvName: kA it A\j Bldg. No.: City: Zip: f6 Facility Contact Person:��,,_ ,>_k p m a s) Contact Phone No.: n fi) 91/8 — Z 6 / ,9' Make/Model of Monitoring System: -7 t--5 '3 ® C) Date of Testing/Servicing: I -Z / 2 8 / 0 Site Address: B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicate meeffic ul Mt inspected/serviced: Ta -7 or ---7 Tank ID: I-flju-Tank Gauging Probe. Model: V11 A ra f -Tank Gauging Probe. Model: rW A 6 ular Space or Vault Sensor. Model: _7f) y 300. /Za ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 7 -7 1/3F,0- 7; og Piping Sump / Trench Sensor(s). Model: 21114/3 FX) - 7 0 ❑ I Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: -1I 4echanical 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 ui ment a and model in Section E on Pae 2). ❑ Other (s eci a ui Ment a and model in Section E on Page 2). Tank ID: 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: 0 Piping Sump /Trench Sensor(s). Model: Cl Fill Sump Sensor(s). i Model '❑ Fill Sump Sens 11Model: ❑ Mechanical Line Leak Detector. Model 13 Mechanical Line Leak Detector. Model: ❑ i�fectronic Line Leak Detector. Model. 13 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: her (s eci a ui Ment a and model in Section E on P e 2). ❑Other (s eci a ui Ment a and model in Section E on Page 2). user ID: l "r 2— Di eraser ID: `f PDwienser Containment Sensor(s). Model: `?JV3` 0-%O ispenserContainmentSensor(s). Model:ear Valve(s). hear Valve(s). s enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: - Dispenser ID: ❑ Dispenser Containment Sensor(s). Model.: Q-tispeuser Containment Sensor(s)...-Model: ❑ Shear Valve(s). h ❑ Shear Valves . '- ❑Dis ❑ Dis enser Contain nt Float(s) an in(s). f ensr Containment Float(s) and Chain(s). i' t Dispenser ID: I f Dispenser ID: s' i ❑ Dispenser Containm rat Sens (s). Model: ❑ Dispens�r Containm t Sensor(s). Mo el: ❑ Shear Valve(s). ❑ Shear Vatve( . /� ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser 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 Certification is information (e.g. manufacturers checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment: For any a Ornent capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up jV Alarm history report Technician Name (print): -7o Qtv\kv_,,a S-1gnatui Certification No.: t t 2) Monitoring System Certification License Nt + c '-I - r 4716