COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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i. � � s r L 'QUALITYTESTING OF UNDER GR0UND TA MKS ATAFFORDABLE RATES, 416 2nd Street , Galt, CA 95632 (209) 744-0112 FAX 744-0116 General Inf rmation ® e Facility Name: f / Cu 5 [ Bldg.No.: . Site Address: /� ,�-r f vrL�L �`, City: °`�' Zip: Facility Contact Person: Contact Phone No.: Z 4't�a,0 .:Make/Model of Monitoring System: ,�� "A c Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment" ected/serviced: Tank ID: cC Tank ID: a� 13Epping k Gauging Probe. Model: �_ - ank Gauging Probe. Model: "I" ar Space or Vault Sensor. Model: W ® ular Space or Vault Sensor. Model: D 00 1.❑ Sump/Trench Sensor(s). Model: Sump/Trench Sensor(s). Model: yL00,00 lb ump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: UrMechamcaI Line Leak Detector. Model: ec anical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Overfill/High-Level Sensor. Model ❑ Tank Overfill/I-Egh-Level Sensor. Model: ❑ Other(specify ui went a and model in Section E on Page 2). ❑ Other i2ecifY e ui ment type and model in Section E on Tank ID: Tank ID: ®R 13 In-Tank Gauging Probe. Model: 0`197T Gauging Probe. Model 2241 . -7 ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. .Model: . ❑ Piping Sump/Trench Seasor(s). Model: rpm Sump/Trench Sensor(s). Model: ❑ Fell Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ® Mechanical Line Leah Detector. Model: Wl3ednui62I Line Detector. Model; O Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model• ❑ Tank Overfill/High-Level Sensor. Model• ❑ Other(spEqn NuiEment a and model in Section E on Page 2). ❑ Other( eel equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Contaimnent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: '�;-l'1 ❑ Shear Valve(s). ❑ ShearValve(a). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Di 'eraser Containment Float(s)and Chain(s). Dispenser ID: Dispenser IDt ❑ Dispenser Containment Sensor(s). Model: 5016 ❑ Dispenser Containment Sensor(s)., Model: 004E ❑ Shear Valve(s). ❑ Sbear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dis enser Containment Floats)and Chain(s). ' Dispenser ID: DispenserID: ❑ Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: uhearValve(s). E3Shear Valve(s). s 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 inonitoring equipment: For any-equipment capable of generating such reports,I have also attached ii copy of the report;(check all that apply): ®System set-up ❑Alarm history report Technician Name(print): Lim 'I\\.,Mtry n Signature: Certification No.: License.N .: CC 52.Ll9115 - Lt Monitoring System Certification