COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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a-awnty vmmu. - rr- f rsiag. 1V0.: Site Address: zae-) P City: 57 G° /-0 /-7 . Zip: Facility Contact Person:4 Contact Phone No. J(� 0) `I/ Make/Model of Monitoring System: rk7 Date of Testing/Servicing: r /.:-L/,/ " B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment insuected/serviced: Tank ID: r, kt Tank ID: y /,/ U-�In-Tank Gauging Probe. Model: C -hi -Tank Gauging Probe. Model: �1 G annular Space or Vault Sensor. Model: 5 ❑-Annular Space or Vault Sensor. Model: ErI ping Sump / Trench Sensor(s). Model:e t U-ilgping Sump / Trench Sensor(s). _ Model: ❑ Fij Sump Sensor(s). Model:13Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: ,EJB l Q--Me—chanical Line Leak Detector. Model: 1 ' A f l% ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s2ecify equipment a and model in Section E on Pae 2). ❑ Other (s eci ui ment a and model in Section E on Pae 2). Tank ID: Tank ID• i ❑ In -Tank Gauging Probe. Model: U -M --'Tank Gauging Probe. Model: 4`, ale ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ,k^� b ❑ Piping Sump / Trench Sensor(s). Model: D-rip—ing Sump / Trench Sensor(s). Model: Wil- S El Fill Sump Sensor(s). Model: EJ5ILSump Sensor(s). �TGy4 Model: ❑ Mechanical Line Leak Detector. Model: MMechanical Line Leak Detector. Model: / =:1- I L7. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: P ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci ui ment a and model in Section E on Page 2). ❑ Other (s eci ui ment a and model in Section E on Pae 2). Dispenser ID: ,J E 7;- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model! ��_ ❑ Dispenser Containment Sensor(s). Model: 5 ❑ Shear Valve(s). ❑ Shear Valve(s). �i" ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser 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). ❑ 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 ofmonitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check aQ that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): L �fi� r�7 yFa9f� Certification No.: C� Monitoring System Certification Signature: License. No.: