COMPLIANCE INFO_2004-2008 - Laserfiche WebLink

Home Browse Search

ne �` Bldg. No.: Site Address: 0 L4>� 2 {� ` "Uk i;P City: � � -§ 1 Zip: T5,10 2 - Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: \{ 1 TL c (i Date of Testing/Servicing: L?Z/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speciric equipment insuected/servicedc Tank ID: % k) ;j A'In-Tank Gauging Probe. Model: M (t nular Space or Vault Sensor. Model: — Piping Sump / Trench Sensor(s). Model: a9' ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: 1_13) ❑ Tank Overfill/ High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). T kID: In -Tank Gauging Probe. Model:(^ j�Annular Space or Vault Sensor. ®� Model: 11 Q' Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: JU Electronic Line Leak Detector. Model: ❑ Tank Overfill /High -Level Sensor. Model: ❑ Other OMEgy a ui ment e•and model in Section E on Page 2). Dispenser ID• 1 3 XDA* penser Containment Sensor(s). Model: (� Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: --J 7-7 �dqispenser Containment Sensor(s). Model: C-sf 1 ,del Shear Valve(s). ❑ Dis user Containment Float(s) and Chain(s). Dispenser ID: cl � jai �spenser Containment Sensor(s). Model: _ ! Jd Shear Valve(s). ❑Dispenser Containmefit Floats) and Chain(s)_ Tank ID: Itl � Tank Ganging Probe. Model: M G t Annular Space or Vault Sensor. _G! Model: �) ;}'Piping Sump / Trench Sensor(s). _ Model: 13 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 'Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (sp equipment pe and model in Section E on Paee 2). Tank ID: T) ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump/ Trench Sensor(s). ❑ FillSump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (s eci ui ment a and i Dispenser ID: )a penser Containment Sensor(s). Shear Valve(s). . . ❑ Di user Containment Float(s) and Dispenser ID: 4 bbearpenser Containment Sensor(s). Valve(s). Dispenser Containment Floats) and Dispenser ID• _ )____(;�_ Pf Model: Model: l Model: Model: Model: Model: Model: iodel in Section E on Model: 0o) Model: D�spenserContauunent Sensor(s). Model: __ b �3"5hear Valve(s). ❑ Dispenser Containment Floats) and Chains) *If the facility contains more tanks or dispensers, copy tins form Include mformatron 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 4pertificatlon is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the ls►yoat of monitoring pment: For any eq went capable of generating such reports, I have also attached a copy of the report; (check aQ that apply): ystem set-up l" m t y report Technician Name (print): _ Z A/f A it;, 42 -, Signature:_ Certification No.: License. No.: _T AL SZ..& 3 2 9 UT