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f Ja r i"i'm <br /> 7 <br /> 'V1111/./r)- TPAWNr(11; ern'nrlr(;Ir(lf/Nl) 7:1N!'.5'�1� ,II-Lrur�-l�1ir .� <br /> J'o.c! ) Il <br /> ce es -i6 )"horntom Ca. 9.5686 (209) 794-Or02 l,ifi��94-0112 <br /> 1I� <br /> DEC 0 3 2002 <br /> (:yncrnllllft�rQ�l�i(SI ENVIRONMENT HE TN <br /> fa(illl Nontr rlilp. Nrr.:- - <br /> Site Addrrss: _ _ 15l b �p e. Za h ' �� ,;,,,. I�Op HERMIT/SERVICE 7.ilr. <br /> Facility OmIncl Prrsrrrr t',ntlnct I'hnar IJn (a�(� -h yo - <br /> Mnkr/Madel of Mnnilrninp:yslrnr I%� �1� `( � � bore ill 'Irslin)!/.r;crviciap: t7y/4 � <br /> 1{. Invel►1(ny (►f 1?ytlll►nu•nl 'I'('sl(•d/1 'cr lili(•d <br /> Ureck now apponpilmole boxes Io Indicates ecltic r,of anrat for rrr ted/ser,It rdt <br /> 1 sole 11► <br /> , <br /> Tank II):�/e_ _5F_�- � _ - ----- <br /> C�In-Tank (rn i in 1' br Mrnlr l ?IGt' l) In Imtk I lnupinp 1'rnhe MrHlal;. 11l_. � <br /> R Rrm �gIl'J`3LTAmminr S,ncr tit Vn oll Sr-nsar Mnrklt �.`�yr 37 "1. <br /> �Am mlar Splice(it Vnolt Srnaa„ A1r�ilr <br /> C) I 7..._ <br /> Ll'i'iphrR Sung,/'t+rnrlsrrrrr�«r(�1 A1r.IrJ -�7 O?0/U3�U 7d2 l.�'il.inp Sunil,/ Irrm h Sriv:m(s) MrHlrlt�`a/ -.---- <br /> / rryy <br /> (3�(rill Sump Setvitt el al,olrl -wd �t 'C LI fill SungrSravrr(�) Mndrlt j•.`1_p__. _"—, ^OY <br /> LJ�Nlrclrxnirnl I.Ine Ink I+rtrclnr K1n,IrI STP <br /> r+xA-0-O LTMrchnnl(•r,l line 1 r.,k I)eir:rrr. MrHlrl•S �l;'i•C'O <br /> t '` NimIrl -7�1 .4r+Q �/°�ILl �j- L-t V'Y f� MrHlel:� <br /> I "d r ` t.� a - r' U 'I nnk()vevfiII/I high I evrI Srrtsor. A9ude1: <br /> ❑ 7 oak Overfll{i Iligh-1 suet Sensor. MndrL' _ <br /> O Other(specify equipment t and model in Section G on Pri e 2). U Other (specify a ui nment type and nxxiel in Section B on Pallia 2). <br /> Tank ID: Tank <br /> O In-Took(rouging Probe. Mintel rMI �, U In '{milk (rouging Pmbr. <br /> U Annular Space or Va11I1 Sensor. Mnrlrl �) a')a U Amminr Spnce lir V400441XW. Mrxlel: 1.Z 0379 r< 'D''er�7 <br /> O Piping Sump/�+►(e). Madel +f-"(�"� r U Piping Snmp M(alelt iLI,4 <br /> U rill Sump Sensnr(s). MrHlrl• 3Z 'V10t" U Fill Smnp Srosnr(O M(Klel:#4-),O— <br /> U Mechanical bine Renk Delr(•Inr. Mnrlrl• S7)""if-4' U Mrrhnmir„I I.inr I rnk Do-Irrim. M(Hlel: Sr h"16' <br /> O Mr SLA vvl jJ MfOrl.L-_.;60 qt,+,'' U f111 rCsP 5 u vii Malek 1=`1 I ;;7 <br /> ❑ Tank Overfill/111gh-I evrl Senear. Mnrlrl: U 1 link Overfill I Ilight-I ever sensor. M(Hlel: <br /> U Ober(a ecif ui invent 11)e and rm(lel in Section I?on I'lle. 2). U other(specify e(ui«Ment type and nHHlel In Sectitm E on Page 2). <br /> Tank ID: �i �� -� -- - - 'Tank II): <br /> ❑ In-Tank Gisuging Probe. Madel: %?2(�l .� U In Tmik(longing l'rthr Malel:_ <br /> ❑ Annular Space or Vault Sensm• Madel: U Aunulnt Splice of Vnult Sensm. M(xlel: <br /> O Piping Sump/ .0 Model .- U 1'ipinp•Sump/Trench Srnsar(s) M(micl:.-- <br /> ❑ Pill Sump Senvrr(m). Madel: ' ! °V'=� U Dill Sump Srnsm(.), _..-- <br /> U -Mechanical I.Inlr enk Driecillr. Klmlrl' U Mrcluu+lcul I.Ine I rrrk Drtrclr+r. MrHlrl: <br /> A <br /> 0 AA` ( 5 a{ e vl 13 Mndeh'4'92'1/ ;A rJ C: . U Nlrchnnl( I.Inr I.rnk I)etrclar. Malel: <br /> O Tank Overfill/ing..-r ..a:,sensor. Model: _ ..- _ - U 'funk Overfill/Iligh-Level Sensor. Madel: <br /> O Other(specify ui ment type and model in Section C un I'n c 2). U Other(specify equipment 1 and model in Section E on PW 2). <br /> Tank ID; _ _ 'took <br /> O In-Tank Gauging Prulm. -- --Model: U hr-Tnnk(rouging I'rrrhe. M(oal:_ <br /> O Annular Space lir Vault Senior. Model. U Annular Space m Vanh Sensor. M(xlel. <br /> ❑ Piping Sump/Trench Semnr(s). Model• U Piping Sump/Trench Srnsol(s). Mtate):_ <br /> U fill Sump Sensor(s). MrHlrl' U Dill Sungr Srttsm(e) M(Hlel: <br /> ❑ Mechanical bine beak Drleclor. Mnrlrl• U Mrchmnicnl Line I rak Drlectrtr. Malel•_ <br /> ❑ Electronic Line Leak Detector. Mendel: U Illecnonic Line Leak Dclector. Model! <br /> O Tank Overfill/I high-I rvrl Sensm. Model: . U I nnk Omfill/I ligh-I evel Sensor. MIHIEI: <br /> ❑ Other(specify equipment type and model in Scctiun N au I'lle 1). 1 U Other(specify equipment anent 1 H•and nHxlel in Section Ron P e 2). <br /> "if the facility contains rune tanks or dispensers,copy this farm hiclnde information for every tank and dispenser at Ilia facility. <br /> C. Cer(Incalloll - 1 certify flint the rqulpn►rnt Mrrrllllyd In Ihls 41mu►rrrnt was h►9pec•trrVoerviced In accordance wills the manufaetueez <br /> guidelines. Attnched to this Certification Is Infmnnnlion (e.g. mamtfaclurers' cherklisb) necemary to verify that tllla Informatim V <br /> correct and a Ptol flan showing the loyoul of monllmhrR rgrrllrrrrenl. For o►►y rqulpn►enl rmpnirle of generdlnR such reports,1 lova tubo <br /> ■Ilached n copy of the reff ori;(rherk ill(_ eat nppiv): U System art-up U Alanr)hlolory rrpc►rt, <br /> Technicinn Name(pvimt): /�t�I�P A.' '4'14 f+c(� tiipantmr t�T',. <br /> Cerlificistiar No.:. �i'rf"�f- r'� I i,rose NOW 6�t <br /> Testing Comlinny Nnnte: /9T,y t-J" " re S f- I'hanc No :m/�g <br /> Page 1 QVIII <br /> MonllarinR St•slrrn ('rrllflenllnn <br />