Laserfiche WebLink
r <br /> \7 f <br /> hw+ Ll <br /> 'QUA1,17T TEAUNr;()r'11Af1)rlt(,'1t(1rlNl) 74Nh�.VA7'�Ir;Tr)ltl)�All r:'n,47'l S" <br /> ' ' <br /> POST Ojflce Box .1 G Therittim, ( (1. 9568 (200) 794-0102 1%it.Y 794-0112 <br /> General I Ilforina l ion <br /> Facility Name: pdU U �+ f C <br /> i� Bldg, No.: <br /> Site Address:—_ d0 p + - <br /> `� _� 7.i1�: <br /> Nr.ility Cnrrinct Persr+n: ,� --- <br /> 1°tolfnrl Philrfr Nn.: <br /> Make/Mrlctrt o1 Mollilnlink Syelr•o1 <br /> �- YiSb 11n1r til 'i'rcfinl±/,5rrvirinl;: / lt? /© <br /> it. inventfory (of EfI1lllrtneful 'l'rslr•fi/l 'trfiliccl <br /> [beck the■ ra dale hoses to Indicate specific c ul nlenl hu rrrfcd/art l•Irctl: <br /> Tank 1D: =_,> �i ur. ��.,' , _ 't'erfk i[►: <br /> In-Tank(+mrRinR PFnhr. ImIrl: YY)iQ <br /> Annnlar Spare nr Vaud Srrl9nr. Aiodrl: _ lo- nnk Opoltinp 111t4hr. Model: <br /> Annulnf Spare fa'Vnllh Sensor. Mndeh ee 4� 00 !A <br /> Pilling Sprpp I TreflCll SenRITF(S). M/lrirl:_I r1 rf t3o`�0.1 piping Srr1n11 I�I�fr11CI1 SC.I15nf(S). Model: � 5 80 - dam, <br /> J31J Sufnp 5en9ot(tl. {�( pi?uw+t M+ulrl' t/jQp• ?,oEs <br /> U Mechanical IJrle I enk I>rtrrlor. �Mntlel: 5ir1191 SrnFnr(al, !'�a�SviPlydvtlfrlrl;_ � O Zd <br /> ❑ Hleclronic Line[.enk Defector. A}ntlelr U Mrt•Itnnlcal Line Irak Drlec•tor. Model: <br /> U I?lrcllanic Lille i.enk Deteclor. Model; <br /> ❑ Tank Overfill/high-revel Sr"Flor. Model; U Tnnk Overfill/fligh-Level Sensor. Model: <br /> ❑ thine(s if ui meal t and model in Section P oil I,n e 2 . U Vdrer s ecW ui mcnt t and model in-Rection <br /> Tank f[): 0 C-11� _ 3 'rank I1)• <br /> 14 In-Tank Gauging Probe, Mnclel; U to-Tank(iaoglnR Probe. Mndel: <br /> la Annnlar Space or Vault Serl9or, Ml/ttel: �Jy3 yc! <br /> U Annnlar Space nr Varrlt Sellgor, Model: <br /> i.Piping Sump/Trench Senenr(R). Model: �4- U 1'ipillA Srrfr,p/'rrrncl,Sen9r+r(s). Mcxfel: <br /> 1 Sump Scnsnr(a).�'!)a`afn�5cynP Mrlrirl;?9 /.�F3Q �?„ U i il!,Salop Srrrtctr(9). Merrlol: <br /> ❑ Mechanical Line Lenk Detector. Mndel: U Mrrhanill line(rak Urlector. Mrxlel: <br /> ❑ 8lemmnic Line f.,eak Detector, Mnrlri: V 1?irctmnic Line i.rak Defector. MexieL• <br /> ❑ Teak Overfill/I(igh-Level SenRttr. fvtndr.l: U 'i'nnk f)vrrfiil/I ligh-Level Sengnr. Mrxlel: <br /> ❑ Other{e xir ui rnent t and model in Section L toil 1'a e 2 , U Vlher s cell ee ui rrrertt f and lncxlel In Section E on Page 2). <br /> Dhipenser in: DiRPenver 11): <br /> U Olen Val ('nrrtainnrrnl Srnsorlg}. A7nrlrl' U ilimpellger('nntainrnrIII SrnRo1(R)• Model._ <br /> ❑ Shear Valve(s). U Shear Valve(s). <br /> U Dispenser Containment floats and Chain(s), U Dispenser Contaimrtenl Iloat(s and Clsain a . <br /> Dleperwer lD; ---.--- - Dispenser ID: <br /> ❑ Dispenser Containment Sengor(s), Mnrlri;_� U I)iapenser Conlnntntent Sen,snr(s). Madel: <br /> ❑ Silent Valve(is). ___ . ._ __ U Shear Ner Ctin. <br /> ❑ Dis nser Conlaimnenl Moat(s)and t llain(s)' U 219 nser Cuntair}aleat floats and Chain(s). <br /> D"erkser 1D; _ Dispenser ID: ' <br /> ❑ Dispenser Containment Senso►(,). Mndcl: U DlRllenaer('llnlninplan SCIISnr(R), MtxIEI: <br /> ❑ Shear Valve(g). - - 1 I Shegr ner C R). <br /> ❑Dia nser Containment Floats and Chains . U ills nser e(N). irtnfent floats and Chains . <br /> *If Ilrc facility contains ranee tanks OF riiRperrsrrs,copy t{oil fro an. Inrlutlr inforroalion rnr every imfk and dis{reneer al lira facility. <br /> C. CerllfiCllliUil -1 certify that the rrinlpmeut Irlrnllfird In ih1R document waR 11rspeelrcVeervicrel!n accordance with the manufacturs' <br /> guidelines. Attached to this Certification IR InrnrmaNntT (r... ntanne <br /> roclurers' clseckiista) necessary to verify that (lila Information III <br /> cornet and a Pint Plan Rhowing the layout or nronUorille r f patent. For any ecln pnaenl rapahle n�In such re <br /> allached n copy or(he report check all rhaf 1pit j g lm�*l eve also <br /> Vnb Re�tir n igt re fort <br /> Techn (P <br /> lcfatT Narrrc rind: <br /> Cefliflenlion No.: `�` ,� <br /> I.irr'nsr• No.: E� <br /> I'nRr 1 of 3 Q3/ot <br /> M1lcrnllnring SI•stertt ('crtlfirnlinr) <br />