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SYSTEM CERTIFIOAL'I'lopj l�ur !!srCir d/IJrrr•isxlic•liurr.+• ll'illurallrc^,57ulcraf('rrli/r,r•rricr iu/IrvriJv C'iler/: C'hcyfler t.7, /Ic^ul�lr crrrrl 5'uJclt^C'urk, C'hoj)rcr It I)ir•isi0i7 3, TiNe 33, C u1r 1nrfrkr Codec3f'/,'c' uluNuns This Harm must he used to document testing and servicinrT of nianitorinJ a pared for eacli_rnnnilcrin system control nand by the technician wlto pe foitnslthe work. se taarate erotic rtion car reura_11'st be the tank system owner/operator. The owner/operator must su Twilit a copy of this for-rat to l i a be provided to within 30 days of test date. ar t'1�UST symt nts A. GeneralInforMation Facility Name: 4AICA oa � JUS. 2 � �0� Site Address: / ,�� p�r It g• T City: � -P4 lR POENT FEA1T 2A5 Facility Contact Person: Irl r Contact Phone qc f Male/Model of Monitoring System: 5b Date of Test /gyp/pg B. Inventory of Equipment Tested/Certified Chccic the a a rn Ir ioate ho.ees to indiraEe s iec•irrc er Ili nurat ins Iected/semicerl: Tank ID: r ��7 Tan lc ID: 0 in-Annular Gauging @rade. Moilel: � / ❑ In-Tank Gauging Probe. Annular Space or Vault Sensor. Model: ; Model: ❑ Annular Space or Vault Sensor. Madel: a Piping Sump I Trench Sensor(s). Model: /OS ❑ Piping Sump I Trench Sensor(s). Model: � Fill Sump Sensor{s}. Madel: Mechanical Line Leak Detector. Model 13 Fill Sump Sensor(s). Madel: — - ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel. Tank Overfill/High -Level Sensor. Model: � Electronic Line Leak Detector. Model:- ❑ Other(specify e ui arnent type and model in Section E on PaL, 2 , El Tank Overfill/High-Level Sensor- Mo : Tank iD: I 4D C_^r i ) ❑ Other(s ecify a ui nient t e and natt el in Section E art Pa=e 2). t& In-Tank Gauging Probe. Tank ID: g g Model: 4G 1 ❑ In Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor- Model: Id Piping Sump/Trench Sensor(s). Model: 13 Annular Space or Vault Sensor. Model: 708 ❑ Piping St nip i Trench Sensor(s), Model: Fill Swap Sensor(s). Model: O ❑ Fill Sump Sensoils). Model ' Mechanical Line Leak Detector. Model: •M1.$ . ❑ Electronic Line Leak Detector. Model: — ❑ Mechanical Line Leak Defector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other(s eciry egtsi meat ty a and model in Section E on Page 2 • ❑ Tank Overtul[/High-Level Sensor. Model: ❑ Other(specif ec ui tment type and model in Sec' n E on Pa if?)- Dtspenscr ID; / 'f Z 29 Dispenser Containment Sensor(s). Model: Dispenser ID: A Shcar Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dis eraser Containment Floats)and Chain(s). ❑ Shear Valve(s). Dispenser 10: djr ❑ Dispenser Containment Flow(s)and Chain(s), 23 Dispenser Con[tiinnterit Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: X Shear Valve(s). ❑ Diseraser Containment Float(s)and Chain(s). ❑ Shear Valve(s), E) Dispenser Cantainnient Floats)and Chain(s). Dispenser ID: 18 Dispenser Containment Sensor(s). Model: . 0 Dispenser ID: 8-Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model. ❑Dis enser Containnient Float(s)andCliain(s). E3Shear Valve(s). *Wthe facility contains more tanks or dispensers,copy this form. Include in ormation for everyrtank andld spertserlatltlierFaci ity. C. Certification manufacturers' - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the rnsinufachtrers' guidelines. Attached to this Certification is inrormation (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piof Plan shoivirtg tlac layout of monitoring equipment. For any equipment capable of generlaking such reports,l have also attached a copy of the report;(check n/I la ripply): bSyste t-u arm histol y report Technician Name(print): Signature: Certification No.: ee tz Q License.No.: ej Testing Company Name: * Phone No.: _� oz Site Address: Z� �4Qv � _ Date of Testing/Servicing: '''' IVionitoringSystetn Certification Page I of 3 03A)I A Results of Testing/Servicing