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sIV s) • .0 • fO Mnkr/Motolel tof Monitor' ing SynIrno: Ci 1104or c.) Fiiiie. !tone itt I cslietp/Sci vicinp: 2 /JO / 63 Site Address: /5-T3 C:1 1(2"--71 1Q-AW? ENVIRONMENT HEAT HQ ( /0.5.1-, 0._‘..,. ... Facility ( omIncl Pelson: ) / 1-1-1 F 0 r 1 - 1 0.. K PERMIT/SERVICES i .4.00Ini I Plumy t'lit • ( -p Of ) 6-9. 9.••••_P , ',D. Facility Name: Ci • Geiser-ill Iirforritnlion - .. SEP 2 9 2003 Illolg. No.: . . IL Inventory of Equipment Tested/I 'el Mica Cited' the app. opt lode boxel 10 11101(111r eptC111C rtimilevrros in Iry .1 . w 1.'1.1 . .....• Tank ID: 21/ _ _P! ..,-_-....-ey 0, ,' i- 'TY Uln-Tettik ( ;retying I'mbr Mot h+ 4,2.2 3 U-16 lot Spore ni Veld( Sritgori 1\14 ,11r1.1-7 7 4 -3 610-4 9-V g(t) (1/4 1,ttlflet? *;,:`."(°` F'el,-...-7(7.,' Ul'iplog S * I .10corlo Srlem U-Y4fiS r Srevit to (1) N11,01.1.A-0 • -1.0 E-- Iff Alerlinovirn1 I ine I rnk I Imo-coos t%loolrl 13 ' 4. 17 - 0 0 Elect In Linn I.enk I/eft-Mot Mimic!! D Tank Overfill / lliglo-I rvel Sensor. Model: _ . OOther (specify equi mem type nnd model in Section E on l'nge 2). .1 nook II)! 7: 2._ 7."7 / r • 5 v./ 5- v c. (--* . ........_ _.... u 1,, .imik I inopitip Probe Mill In: '127.444' 1.-_r-A Int Spore° 111 Vnoll Srwtri Model: );•"/ /. 474541)- 4(:). -----A-f- t .e 1.1-riv ior Simile / 'Irroch Sront ,t(e) 11.11sulrltk%-• • .. Li rill S Srilq(.1(.1). M.,411fItif-.1 Cs' it LrAfro lotonlen1 Hour I rok I irtrctot. Model: 47-ti2411 A Q7 U Pleritooln I live I f-nlU inook r /vet fill / Illglo- I eve! So-moor. Model: U Other (apecify equipment type and tumid in Section B on Palos 2). Tank Bs: 7 bt. 14 L. ./.,4 P-'4, r rov fri,iy P-24,5i,or -1-..,k in! Li In 'Intik Onorping Probe.' Model: o In-Tank Uptight& Probe. Moiled". l7nrc.73 0 Annular Space or Vault Sensor. Model: 1.--1 1 -11,.,,, 0 Piping Sump / Trench Sensm(s). Model: t--161 74141`31rP - --P L-2- - 2 7 ,g4-50-0- x-az U Fill Sump Sensor(s). Mintrb U Mechanical Line Lenk Detector Model. 53-4:14141"-V 13 Electronic Line I .enk Deter-ton. Model: (3 Tank Overfill / High-1 rvel Sennoti. Monied: . . 0 Other (specify equipment type and model in Section 11, lin Page 1). U Attimlni Spnce in Vault Sensor. Model: 4:- /.2 7. '-</390 -- U Piping Sump/ 'french Sennot(p). Model: A -- / 3 Li rill Stomp Srooson(e) Model: /._-/b U Merlormirn1 I lute I rnk I telecton. Model: • U Electionic Line I I tetector. Model: .enk U 'Intik t Neifill / 1411.1 rvel Sermon. Model: U Initer (specify equipment type and model In Section Bon Pep 2). , Tank ID: Tnnk II): 7-.4 cifiar='ff" U In-Intik flanging Nolte Model: ///,:=4,‘.3 7 0 In-Tank Hanging Probe. Model: 0 Annular Space or Vault Sensor Mould: . LI Piping Stomp / Trench Sensoi(s). Model: 13 Fill Sump Settpon(s). Monk!: LI Mechanic:id Line Leta Drirelon. Mould. 3 Electronic Line Leak I/elector Model: 3 Tank Overfill / high-level Sensor. Model: _ _ _ . 3 Other (specify equipment type and model in Section E on Page 2). U AmmInt Space in Vnull Sensor. Model: • -6- U Piping Sump / Toettch Sensor(s). Model: /-----"V -3 74/475.0 U Fill Swoop Sroonon(oo). Mould: [7:17 ''.1.14;61'"42443- Li Alryloonolrool I ion. I rook I trier-rot. Mould: ..2r,k . iiii C .1 U Pletionrolc I inn 1.rnk I irlector. Model: , U Tank Overfill / I liglt-I .evel Sensor. Model: U Other (specify equipment type and model in Section E on Pax° 2). rank II): Tank II): Li lit-Tank (hinging Probe. Model: 3 In-Tank Hanging Probe. Model: 3 Annular Space or Vault Sensor. Model: . 3 Piping Sump / Trench Sensm(s). Mudd: . 3 Fill Sump Sensm(s). Model. 3 Mechanical line I zrok Detector. Model. 3 Electronic Line leak Detector Model: 3 Tank Overfill / I light xtvel Sensor. Mould: . 3 Other (specify equipment type and model in Section E. om PitEe 2). U Annular Space on Vault Sensor. Model: Li Piping Sump / Trench Senson(s). Model: U Fill Snoop Sroosoo(n) Model: Li MrclinnicnI Line I ink I )(lector Model: U Flectronic Hue I rook DelecIon. Model: U 'I nook I /ver fill I I light rvel Setinon. Model: U Oilier (epecify equipment type and model In Section E on Pge 2). lithe facility contains mote tanks or dispensers, copy this helm include information for every rank and dispenser at the facility. i. Certification - I certify that the equipment Identified lit 11:11 document was Inspected/sew vIced in accurdance willr the messutiecturere guidelines. Attached In this Certification is inhumation (e.g. mainifecturm. checklists) necessary to verify that this intonnetion Is correct and a Plot Plan allowing the layout cof mooltollota eoptIpmenl. For any equipment capable of generating much reports, I have also attached a copy of lbw report; (rIrreh all drat apply): U Svntem act-lip U Alarm hiatory report _ 'echoicinn Mime. (point). Sitonottior• , 'erlificntion D ).) 1-1 6 1•11KI• 1111 9`") 'esting romprmy Name: fe- 1./ P. 14 r 4'7 Page 1 of 6 0.1101 Pitforb-a-Te /A/d/T 7VST/M; r Yr. I IA'111;1(1;1(011NI) liINKSAT/1/441/1/.)/1/ILE 8,4 TES' Post Office Box 36 iliorrt(or4-j*,;,1646171[109) 794-0102 FAX 794-0112 Phone No .( loulloring System