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it � � »eft►1] j <br />f f n r tri-'c�Ie�t <br />VIIA1,177 71,.S711V(; (1l 1'A'l►l K( NO11N1► 71IN&A'A7'111441/1l),1111,F,'HATES' <br />.1'osf Ofjic•P V S <br />Box 36 )"horfaim, ((r. 6N(, (ZU9J-�Sr4-01(12 <br />PH 1:48 <br />;7X 794-0112 <br />Gerfernl Infornlnlinn <br />fj In -Tank (inuging Probe. <br />Model: rrr%-Y r <br />Facility Name: L,O u 'P_ 'e- 'Uo" I <br />C P l r �' v -'Y" <br />Mlnlel:._____--_ <br />IIIIIp <br />Site Allthe L <br />: �� d 0 T'C;, d/ <br />rsf�. <br />r <br />model: <br />Facility('11nlncl Vrrsnn+, <br />1'nnlnrr l'hrnv tlrt ( <br />�f%41 <br />J • <br />Mnkr/Mntlrl ill Monilminp :y-1r•nr LA0,a• pir :`'. of jf 1. <br />�, 't`lJ ttnlr r.l Ir clirrl <br />/!;ctvirinp 6 1 -/®� <br />11. Invenl(rt'y (►f I?tlttllnnt•nl '1't'Slyd/1'cr Iilicll <br />Mtrdrl: _ <br />U Mechanical Linr l enk Orlerlm <br />Cheek the roppinfor Iate bores to Indicates ecl(Ic er ul nnrul In. IIr Ir4l.,I ill nlr <br />LI Kicrhnnlrnl I Lrtr I rnk Orlrc(rn <br />_ <br />Mrnlrl: <br />Tank IU: _,r/'e 5 of )!�ej <br />1.1,k 111 Z7/- n "O/'�- <br />LJ_In-Tank (tmrpinp Politic Alnrlrl 17)0'4 % <br />(r/lnnalar Slrnrr m Vnnll Srntm Mrnlrl 1-a9 <br />trt'In IrmkIlrnrp,inp 1'rnt.r <br />1'►' Annolm Slrnrr rrr V null Srrr-m <br />Mrnlrl: .%%%GYM <br />Mmlel <br />L-rNIdnpSnnyt/ Lrrnrir�+.rr...rlrl A1r.rlrl�-�7 O:�U��O -r t <br />l/1'1'il.inr,tiumlr/ IranlrSrn-nr(al <br />Model: <br />Fill Sump Srneml.l Mrnlrl �--3U "`C <br />l.r fill .tinmlr <br />Tank If): <br />L'r-K1rcltanirrrl I tire I rnk I lrlr( lrn M"'I'l <br />(3�1'1't. '^t � .. Mmlcl �--7 FJ � <br />hrmirnl I file 1 r..4 I )rlrr-Inr <br />LTr�'� (� <br />MrnleL STf?nl•O O <br />i r.� L t :, r:'� lr'� <br />1 � tri 1;,.� /-� <br />Mrnlel:�•-r3z a0cr' <br />❑ l ank Overflil i I liph level Srnam. Mrnlrl .. <br />U 'I milk Overfill / 111gh l evrl ,Srllwr. <br />Model: <br />O Wier r If equipment t ' and mudel in Sectio -on E un I'll&�2. <br />U other (specify a ui mlenl type and <br />model In Section B on P e 2). <br />Tank W., _- ��.- - I't-0 <br />l ank 11►. <br />M(nlel: <br />U In -Tank Gauging Prolre.Mntlrl %Ji W+ �� •vo <br />n <br />U In 'I milk (Jnupinp Visitor. <br />Mlr(lel: j'91ry,:,, <br />Antler Spacr or Vault Srnsrn Mrnlrl') ��� �7`P'�a' <br />U nt <br />U Amm1nr Slrnrr fir Cr ill, <br />M(MIe1. k-lz <br />U Piping Smog /+fYAp>wls tsan(a) Mrnlrl `/ '"`2)F- <br />U I'i tin , spoor t / 1mrKhPRr"'r0P" . <br />Mlxlrl: ---) �4 <br />U Fill Sums Srnsnr(s). Mrnlrl' 4-J2 <br />I I fill .r:nmrll SrrlRI)l <br />Mltllel fl—/p �h " <br />U Mechanical bine Beak Ortruim Mrnlrl S 7,F" "l <br />U Mrt'lran�ip—I 1 inr 1 rnk I )rlrr loll <br />Mrnlel: <br />U IVlt1 JU✓II Mrnlrl'1 �O ',G'�' <br />L1 M, '&f SU lit( J3Mtmlel:1__l <br />in Secliun 11 loll l'ukc 1). <br />U Tank Overfill / IIigh-t evrl Senam. Mrnlrl' <br />U 'I nook Ovrrfill / IhKit I evrl tiensor. <br />Mintel: <br />G Otlm (Ipecify equipment type end model in Secliun I? on I'Irpr 1). <br />U Other (rpccify eflulp ne'llt type mild rtrlrdel In Section E on Pete 2). <br />Took IU: � ki V— 11 (7. _ <br />_ ._ ._ <br />'I nook ID: <br />fj In -Tank (inuging Probe. <br />Model: rrr%-Y r <br />U In Tnnk Omupinp holle <br />Mlnlel:._____--_ <br />O Annular Space or Vault Sensm. <br />/ <br />Model: <br />U Amlttdml Sltnce (if Vmtdl Seosrm. <br />model: <br />Q Piping Sump / s) <br />J `�y� <br />M11del / N ^' r <br />U I'ipinp• Sump I] trach Sell[rlt(s) <br />--_ <br />Model:. <br />U Pill Sump Scnern(a) <br />Mndrl'�' ! :> Y <br />U Dill Surrgr Srn.-m(.). <br />Mtrdrl: _ <br />U Mechanical Linr l enk Orlerlm <br />Mmlrl�,/ <br />LI Kicrhnnlrnl I Lrtr I rnk Orlrc(rn <br />_ <br />Mrnlrl: <br />LI S4 �mIrL' <br />' Ir.•{ —J 43 <br />'AA <br />M rf--�-/ '�,<� �j <br />U Nlrrhnnlc 1 .Ine I rnk I )rlrrun. <br />Model: _ • <br />• ❑ Tank Overfill / iirl(.. i .. r .iutsnr. <br />Model: _ <br />U 'lank Overfill / Iligh-1 evrl Sensor. <br />Model: <br />U Other (specify equipment t and model in Section F un Pri e 2). <br />U Other (specify equipment I >e end roodel in Section E on PaXe 2). <br />Tank If): <br />Tank 11): <br />U In -Tank Gauging I'rolrc. <br />Modri: <br />U In 'Ibnk 1 inuging I'mbe. <br />MmIal: _ <br />U Annular Space lir Vaull Semot. <br />Mndr1' <br />U Ammlar Spate lir Vnull Semor. <br />Mntlrl: <br />U Piping Sump /'I'mich SrivuPW0 <br />NIotirl- <br />U l'Illtllp Stltnp VI ich So-mm(s) <br />M(nlel: <br />U Fill Sump Se►ent(s), <br />M(Vtlrl' <br />L: Fill .':unq Srnvm(N) <br />Plrntet: - ____- <br />U Mechanical bine beak hrlrclor <br />Mntlrl' <br />U Mrrhnni(A 1 .inr I rnk I )rlrrl11l <br />Mrnlrl: <br />U @lectionic line 1-enk Uelecim. <br />Mrnlrl: <br />U IllrcUnnic Line Lrnk Dr.let'lor. <br />Mlrllel: <br />U Tank Overfill / Iligh l ever Senam. <br />Mrrdrl- <br />U l ank Ovetfill / I ligh level Srolim. <br />Ml►llel: <br />U Other (rnecify equipment type and loodcl <br />in Secliun 11 loll l'ukc 1). <br />U Gthet (apc(:ifv eouivinent Ivt►e slid <br />naxiel in Section E on Pete 2). <br />*If lire facility contains nxme tanks or disprnsers, ropy lhic (111111 Inchldc information for every tank and dispenser at lim facility. <br />C. Cer(Ificatio11 - I certify Ihnl the rqulpntenl Idrolilled In 1111s dm'nmenl was hnpeclrtVarrvl(•erl In aca►rdance with the lranubeturers' <br />guidelines. Allnchrd to this Certification Is Info( Ilmlinn Wit. ntannfacturew' chrckllsla) nrcemary In verify Ohs( " Informtlow V <br />correct and a Phil flan allowing the In),onl of numllnr Imp ryolpntenl. For any equtpn►en1 capable of generallnR euci( rgwrle, 1 have •bo <br />■Ilachell a "py of file 17,011; (rherA at(that rtlyrlyl: U Nvalem nrl-lip U I1 rn islltlatry ret)r►rl__ <br />Technician Nante (,rlhtl) j/1-PAjr l JI ylt (� `:ip11nllur it : i•>,%1 +r-- <br />C'erlificntinn Nr.: r5L'^"(- R(,If,r•fj- 1 it r'nsr Ila N� �7rr <br />l� A <br />Testing Compnoy Nnntc i7E I ') t'_� 'F I F' %� I'hrmr Nn <br />paqp 1 0.1!01 <br />It1orllnrinR SI•Flpnl Crrlificnlinn <br />