COMPLIANCE INFO_2000-2005 - Laserfiche WebLink

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PCMG►f /) � C�O ® �iW. 3ialEttliy sC/LVA � ! f� farba— Tell QUALITY TESTING OF UNDERGROUND 7ANKSATAF'FORDABLERATES' Post Oce Box 36 Thornton, Ccs 95686 (209) 794-0102 FAX 794-0112 General Information P Facility Name: -,,Et M 4 ( S i ,ro Bldg.No.: Site Address: `� °'�"� ' City: ' A' Zip: Facility Contact Person: \T lit V? ('10 Contact Phone No.: ("_D C )'7Z� `5 of 'o'er 7 Make/Model of Monitoring System: "1`�S 2)3- ) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate ecific equipment i Tank ID:0,7 W 1-- `7'77 777 p- Tank ID: e 0 �- feYfn-Tank Gauging Probe. Model: * / Q'Tn-Tank Gauging Probe. Model: �4-, "nular Space or Vault Sensor. Model: -70-4,310 AIFO U Annular Space or Vault Sensor. Model: -a-0�/ Damping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: EI Fjll Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: : Mechanical Line Leak Detector. Model: �".t-°1� ® Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: L3 Tank Overfill/High-Level Sensor. Model: Ll Tank Overfill/High-Level Sensor. Model: El Other(specify equipment a and model in Section E on P!Se 2). ❑ Other(s eci ui ment a and model in Section E on Page 2). Tank ID: Tank ID: 14 4 ❑ In-Tank Gauging Probe. Model: 2r Tank Gauging Probe. Model: E3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model-(--g 1,'f-r2#At dr -4k ❑ Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: �©6 ❑ Fill Sump Sensor(s). Model: ❑ 13M Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector: Model: OrMechanical Line Leak Detector. Model:Ca L M XZ:Z ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sgeciLt Equipment a and model in Section E on Pae 2). ❑ Other(s eci ui ment=e and model in Section E on Page 2). Dispenser ID: Dispenser ID: 15-t-4 Ll 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). Dispenser ID: )L q Dispenser ID: t��{ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser 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). ❑ Dispenser 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 information is correct and a Plot Plan 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): 6 � �`�* � /1 V*0 Signa ur:,: ~J- 0 Certification No.: S, License No.: Monitoring System Certification