COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

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fforbal-W 'V F, 'V(IAL/7')' 7''rtV77N(; Or•' ( SNI rrr7(rt/r(Y(WI1 7AIV1E'SA7'.lrrr)I?&i)i ;,r iift.0, HEALTH PERMI T/SERVICES Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 EAX 794-0 F "Genernl Inforn Facility Nanre: _S Site Address: Facility Contact Person: Make/Model of Monitrn inR SysU fir 11. inventory of *uesit•tl/t 't'rtilit•rl (aleck the ■onrourlote bores to Indicate sneciric euulnmeni Insuccted/net vivedr f 'onlnr•t ('boor No.: (� � ) %�i� "'$ "�j'�4 �,% rule• of TenlitipNrt viving: J Tank ID: f 'Tank Ill: U In -Tank Gnoging Pmbr. h( I I c Z U III-'1'nnk OnuRing Prohr. - odel:❑ Model.- 13Annnlar Space or Vault Scimm. Mfidrl: +fl'i:A i/ 't? 'G% (.I Anntilrn Spate or Vnn11 Sensor. Model:q0 U Piping Slttnp / Trench Sensor(s).Model ti!} U PIIrR Sump IIrnClSensor s). Mrxlel: U Fill Sump Sensor(s). Morlr I U (rill Snngt Srnnrrr(s). U Mechanical Line beak I/met—lin. Madel: U Mrr•hnnicnl I.hte 1 fink Drlcttor. Mrxlel: ❑ Electronic Line Leak Detector. Model: U electronic bine Leak Deteclor. Model: O Tank Overfill / Ifigh-level Sensor. Modrl: U 'Tank Overfill / Iligh-bevel Sensnr. Model: U Other (specify ui ment type and model in Section E on I'a a 2). U Uther (specify ui ment type and model in Section E on Page 2). Tank IM 'Tank ID: Cl In -Tank Gauging Probe. Model: _ U In -Tank Gouging Pathe. Model: _ y L -4-w st.. 21— ❑ Annular Space or Vault Sensor. Model. U Anurdnr Space fir Vault Sensnr, Model: C-.01, I- 7-1+, e, tt7 O Piping Sump / Trench Sensor(s). Model: U Piping Sump /'Trench Sensor(s). Model: ❑ Fill Snrnp Sensnr(R). Mrxlel:. U fill Sulnp Sen oil,;). Model: _ -U Mechanical Line Leak Detector. Modri: U Mechanical Line I.rnk Detector. Mtxlel: _ ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Mode): ❑ Tank Overfill / Iligh-Level Sensnr. Modrl: U 'Tnnk Overfill /I ligh-Level Sensor. Model: U Other (specify ui ment type and model in Section U on Pae 2). U Other (specify er ui nrent type and inure! in Section E on Page 2). Dispenser 111: / « - Dispenser 11►: i• .! U Dlopenser Containment Srnnot(s). Mtxlel' o 40010" U DiR1x91Re/ Cnntnilmtenl Sensol(s). Mrxlel: "'OP&D U Shear Valve(s). U Shear Vnlve(s). O Dispenser Containment Float s) acrd Chain(s). U Dispenser Containment nloat(s) and Chain(s). pals - _� ;« Dispenser 1D: _ ... .. i Dispenser 1111 - !?:❑Dispenser LI DispenserContainment Sensor(s). Modrl'P}�De? !R�?p CIP—J U Dispenser Conininntent Sensor(s). Model: ,�JiOZ�1 VDDCDilj U Shear Valve(s). U Sliest Velve(s). ❑ Dispenser Containment Float(s) and Chain(s). U Dispenser Containment floats and Chain(s). Dispenser I D: _^. _ _ . _ _ .. _ . Dispenser ID: ' U Dispenser Containment Sensor(s). Model: _._ _..,, • U 1)iRlrenser Contninntent Sensor(R). Mrxlel: ❑ Shear Volve(s). U Shear Valve(R). ❑Dis nser Contaimnent bloats and Chain(s). I U Dispenser Containment Floats and Chain(s). Off the fncility cnntnins rmne tanks or dispensers, ropy this form Include information for every Innk and dispenser of the facility. C. Cer(Ificadmi -1 certify flint the equipnwilt (dentlfird In this dociforrnt was bepectrrURervlced In accordance with the manufacturers' guidelines. Attached to this Certl(Icatlon Is Inforninflon (e.g. tnannfacturers' checklists) necessary to veriry that this Inform" la correct and a Plot Plan showing the layout of monitoring egnlpnrrnf. For any equipment capable of generating such reports, l have sl o attached a copy of flip report; (check, fill/ that firplr): U System Ret-tllr U or n I In l irx�rreporl 'Technician Nnrne (print): �a!<�� /`'�'/' `'�L SiFnnhue: '�`/Ls Cerlifirnlinn No.: _�d�t= Lr'�rif%� I.irrnsr No.: �r�—•//ad%� PORT 1 or 3 03101 MonllnrloR System ('erfif)rnfion