Laserfiche WebLink
SYSTEM CERI ')&,ON <br />A"hor4Cited chap(--r6-7.Health and Saf�&yC4d4-Chqwxl6,Dh*ionJ.7&-ae23.C42WO"daCod--4ofRegutarions <br />11tis furan must be used to document tesdag and servicing of modhodqgcqtapmcnL A MO -ft Certification OrEcOM must be ottiraand <br />for each monitoring system contml nag& by the tcchniciw who performs the vM& A coby of this form must be provided to the tank <br />'YUCUI ownedoperam The owned/operator must submit a copy of this foam to the locd agency =9`011tilIg UST systems within 30 <br />days of test date, <br />A- General <br />Facility Name: <br />M-7.1M.M. 2 elm! <br />go <br />Itt-Ttak Gau&g Pmb,- <br />A=ubrSpace orV=kScn= <br />Piping Sump IT=vchS=sm(4 <br />EWSWUPSORSOC" <br />Mechanical Line LakDaccom. <br />EkctW=Line Leak Ddoc6= <br />Bldg. No <br />city. Z@ - <br />Contact Phone No--( <br />DawofTcsxing/setvidng: <br />0 11-13 o S <br />0 en,rr <br />Mod& <br />aL W. QIQI 11 <br />Mod& <br />- <br />Mod& <br />IAN <br />"g <br />Mod& <br />In -Teak Gauging Pmb--' � .. .. Mod& <br />AnnularSpaccorVault Sensor. Model: <br />Piping sump iTrench scasor(s). modcL--- 2c -Z <br />0 DispeascrContainmentsmsor(s) Modcl:- <br />Shear Valve(s). <br />D4cnscrConUinn=(FlOa9S) and Chain(: <br />Tankin: <br />Mod& <br />A=ulVSp=orVWkS=oc. <br />Mod& <br />0 Pipiz�g Sump /Trench Sensoo(s). <br />Mod& <br />0 FASmWScnscK(s), <br />Mod& <br />0 M=hWkd LTW Leak Detector. <br />14odcl: <br />0 EIc==L=L,=kDcWW <br />Mod& <br />0-T=kOIwfflIffijq,cvdScnsor. <br />Modcl: <br />0 OthcrWq�-.1r.1;requipmcnt <br />b1spensw ED - <br />0 DispcnscrconUiW=(scxISo((S)- <br />b shear vai,,c(s). <br />Cl I)Lvenscr Containruen(Floads) and <br />Mod& - 4 - <br />D' M- <br />0 DispcoscrConiainmentScasor(s)- Model: Cl DispenscrContainmen(Scasor(s)- Model: <br />Shear Valve(s). <br />Shcarvalve(s). <br />Dispenser Containment Floats) and chain(s). 0 <br />I I CI DispenscrContainnicnt Hoat(s) and atainffl.. <br />Dispenser ID: Di ID: <br />CI l)iSpcUscrConW==t Sensor(s). Model: 0 DispcnscrContainmen(Sensor(s). Model: <br />0 shcarvalve(s). 0 Shear Valve(s) <br />ODispenscr Containment Flogs) and Chain(s). 0 DispeasserCon(ahiment Float(s) and Chain(s). <br />off the facility contains more tanks ordispensers, eopythis form. Include information forevay tank and disperser s(the facility. <br />C. Certification . i certify that the equipment identified in this document was inspected(serviced in accordance with the m2nufacbmers' <br />guidelines. Attached to this Certification is information (e.g. manufacturerV cheddists) necessary to verify that this information is <br />correct and a Plot Plan showing the layout of monitoring equipment- For any equipment capable of generating such reports, I have also <br />attached a copy of the r rt; (oh System set-up ;v report <br />— Nn <br />Technician Name (print):Signature14 <br />Certification NO.: License. NO.: - (XjA)L <br />Testing Company Namc:-V <br />rjQ,,,% E E- -Stir-IN-%mr-nA, Phone <br />Si(cAddfess:Z_5Z 1� CA 9(SbrS' Date of Testing/Servicin,( ,:.a <br />