COMPLIANCE INFO_2004-2008 - Laserfiche WebLink

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I - --- - - _ tst g No.:_ Site Address: tl n City: a'r ;, Zip: Facility Contact Person: . Contact Phone No.: (PzQ 19 Make/Model of Monitoring System: Date of Testing/Servicing://¢ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate saecifac eauioment insnect Tank ID: G U _ / U -5 --Wank Gauging Probe. Model: k'11 ': y !�j i Cannular Space or Vault Sensor. Model: 179 L/"tg O ----/ 2-Pi—ping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ectronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). T.'tnk :14 TQ r �P ec onic Line Leak Detector. n -Tank Gauging Probe. Model: R<Tplar Space or Vault Sensor. iping Sump / Trench Sensor(s). Model: �! Model: ❑ Fill Sump Sensor(s). Model: ❑M ical Line Leak Detector. Model: lectron icc Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui ment a and model in Section E on Pa a 2). Disler ID: 4 t� Dispenser Containment Sensor(s). Model:t�g� 0 E7� l _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) Tank ID: -Z t *< LA / U -15 -Tank Gauging Probe. Model: �llae c U-ftnular Space or Vault Sensor. Model: ;?-D G-FT15i Sump / Trench Sensor(s). Model: 0,�- ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ec onic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment pe and model in Section E on Page 2). Tank ID: EFIff-'Tank Gauging Probe. Model: l nular Space or Vault Sensor. Model: 4 aping Sump / Trench Sensor(s). Model: a:- ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID:.- Q 6spenserContainment Sensor(s). Model: / ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(, Dispenser ID: 7 DDis_pemer ID: la � Erbispenser Containment Sensor(s). Model: �D / 13'Dispenser Containment Sensor(s). Model: Cj Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(: Dis_ pier ID: ` ?! Dispe -ID: It) ispenser Containment Sensor(s). Model: OG / Dispenser Containment Sensor(s). Model: 00/ ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) 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 inforination is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment 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): •P < tL Certification No.: Monitoring System Certification r e F Signature:7 74Z `-- License No.: 4�?///-/-