COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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fforbino.-I V HAI,17'I' TES71NG 01;- 11N1)FR(J/101 /NI) 7A VKS A7'A1-rY)1i'1)A131.E RATF..S' Post Office Bev EAX 794-0112 rGenernl Inft)rmatiml 17 Facility Natne: 0 zw v1 D� /0 a- �. r- 04 Ji '0"q kjfo 0 /1 p Ilidg. No.:_ Site Address: _ to q.-2-_ 0, 14 14 12 Y 1�� 1.ity: �U �7�C'��© t-7 zip: Facility Coninct Person! ' Pm t (� CoWnr•I i'htme Nn.• ( ) Make/Modrl of Monitoe ink Symt-m• V' iC • 7 i ►nlr• III Tentiog/Sr► viving:-7_LZ f_111__/ d� If. InvelUory of EflmiPmu•nt Tested/4't•rfifie4l Check the annrovrlate boxes to Indicate snecine eaulntnenl Insaeried/net vlred: Tank ID: I- / � 1-1 P I ❑ In -Tank Clinging Pmhe. Model: U 1n-Tnnk OnuRinR ('eohe. Model: _ ❑ Annular Space or Vault Sensor. Model: 79 3 — U Annnlnr SPnre or Vault Semitic. MrK1el: E)Piping Smnp / T'renclt Sensor(s). Model: "✓'"R> : �("..>a . U Piping Sump /'1'►ench Sensor(s). Mtxlel: 7'dl 4'y `' 2- U roll Sump Sensor(O. Mnrlrl• U Fill Sump Scosn►(s). Model: U Mechanical Line Venk DrIerenr. Mtnir_l: U Atrrhnoicni 1.1ne 1 enk Deleclo . _ „,•,._.___ _ Model: _ O Electronic Line Lenk Detector. Model: U Plectronic Line Leak Detector. Mtxlel: ❑ Tank Overfill / Ifigh-bevel Sensor. Model:. U Trink Overfill / Iligh-Level Sensor. Model: O Other (s if puipment type and model in Section E on Page 2). U Other (specify equiment t and model in Section E lie Post 2). Tank ID:7�� 0ez.-e I _ Tank 11 Cl In -Tank Gauging Probe. Model., Ll In-'1'ntvk (lauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: )6Y15 G0—`/ 'C) U Annular Space or Vault Sensor. _ Mtxlel: ',%. ''r>' :► ❑ Piping Sump / Trench Sen;or(s). Model: -77 '-l' 3 r-0. ; C. tt F U Piping Smnp / Tlench Sensor(s). Model. _� wee :-r PQ— > 0 CC U Fill Smnp Sensor(%).ModcL U fill Sump Sen%nets). Model: O Mechanical kine Leak Detector. Model: Ef $� U Mechanical Line Leak Detector. _ MoIlel. _ ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: _ ❑ Tank Overfill / f sigh -Level Sensor. Model! U 'Tank Overfill /I ligh-level Sensor. Model: ❑ Other (specify ui trent type and model in Section 13 on I'o e 2). U Other (specify equipment ment t and model in Section E on Page 2). Dispenser 1D: / 4_3 Di%penser ID: U DispenserComainment Sensoi(O. Model' Cot U Itisl►rnset('ontainnlenl Sell%1►1(%), M1KIe1:__3 a/a- �r ❑ Shear Valve(s). U Shear Valve(s). O Dispenser Containment Float(s) and Ciain(s). U Dis rouser Containment Floats and Chain(s). Dispenser 1D: 5- - _? Dispenser 11): t'" Y_ ten' ❑ Dispenser Containment Sensor(%). Modrl: _ _ U Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). U Shear Valve(%). O Dispenser Containment Float(s) slid Chain(s). U Dispenser Containment Floats and Chain(s). Dispenser ID: �� Pi -'1 . , Dispenser ll):_' 1 b � JE )'2- 0 ❑ Dispenser Containment Sensor(%). __,_-_.. Model. - ✓ _ � 6 -7/ f,�_o_ /_'_ _ U Dispenser Contninment Sensor(s). Model.- _ 3 ©a /;;? 0 !` ❑ Shear Valve(s). U Shear Valve(%). UDispenser Contaimnent Floats and Chain(s). U Dispenser Conlainnuent Floats and Chain(s). it me raclmy contnlns crane tanks lir dispemeus, copy this loan. Include information for every tank and dispenser at Ilia facility. C. Certifiention -1 certify flint the equipment Idenllflyd In Illi; doirurtwul was hlsperttyVaerviced In accordance with the tmamdacturen' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify that this Informadolm Is correct and a Plot Pian showing the layout of momintino equipnK'nt. For any equipment capable of generating inch reports, I have also attached a copy of the report; (check a1/ that app)r)! U .Systelll set -1111 U A nn Ida �y� ry ►ort Technician Name (pr 1110. V/t P Ili Ili) ,� i� Sirnntme: _ 'Z ! C-�sG%r• Certification No.:� i .itcnsr• No.: Prigr I of ."I 03!01 Monitoring System Cerfiflcntion