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s farba r APR 2 9 203 art rl.l7`}`7'F..SUNi.OF UArt)TRG OUAlt) 7ANh�.� �-rrrrl� ATA A AL't,`Ag dtA T HEAU! r ERU1T/ 'Fi Post Office Bar .16 7hornlorr, ( il. 9. 696 (209) 794-0102 EAX 794-0112 Generltl 1 nforml>i lml Fnc lily Narnc: t 04�-a Lp; ? �? !� iildp. No.:_ 5ile Address: ', 1 �+�, 1'ily o a lilt: Fncility C'manct f ersnn: e / (•nnrnrl f'iinnr• No.- Pate is. lnvpnttrry (rf I+,tlttilrmma 'uestetim 't•r litir•rl Creek the opproprimle boxes to Indicatespecific a ul ment litslit r1rollitet rlrrd: Tank IU: J W�'�-S r TaII t 11t: r IP s't £ Y— CI in-Tank tonging prnhr. Afildr+ ( U ht '1'ntrk GnnginR 1'rr+hr. Model: ❑ Annnlnr Sl+acr OF Vartil Srngnt. Mndrl' `/2 U Annnlnr Spset•e Or Van)(5r,rtsnr. Model:�r` E-0S ❑ Piping Surnp/Trench Srnanr(s). Mntlrl '7G'4 —r�Q� U filling Stnnl,/'I'rrnch Sensrrris). Model: 7cv L.l ; IIOfl F fill Strap,Sell gnr(it). hlt+drl -P Aq 3rrn-M,ta - U' (rill.5uny+Srnst+r(a). Model: U Mechanical Liar I.enk i)rrertnr. M+,ilrl U hirrlurnieell Line I r.rsk 1)rlrr•lm. Madel: ❑ Fleclronic Line Lenk Defector. hiodel: U rlrcttnnic Lice I.eak Detector. model: ❑ Tank Overfill/Iligh-Level Srngor. Modri-. _ ❑ 'I'nnk t7verfill/I ligh-1 evri 5engnr. Madel: [Lou!) Otlter(specify equipment type and rnudei in Sectiun C un pn a 2). U Udier(specify equipment t and model in Section E on P e 2). ank iU: _ ! G - E J� �' y i3c e, '1'nnk i1h In-Tank Gauging Prohe. Mndri: fYNA U In-Tank(intlginR ptnheModel:Annular Space or Vault Senor. Model: ' 44 rsy /d0f U Amminr Space nr Vault Sensor. Mrxlel: piping Sump t Trench Sengrrr(s). Mc,del; 7'7M '3 `a7 - s018_- U piping Snntl+/'I'rrnch Sensor(e). Mrxlel: U Fill Stamp Sensnr(s). Murlel.,-29-11 VS0- 70 F! U fill Sump Srnsnl(s). Mudei:_ Cl Mechanical Line Lenk Detector. ModrL• U Mrchanicnl Him Lenk Defector. Mtxlcl:_ Cl Fledronic Line Leak Detector. Model: U plrctron'rc Line Lrak Detector. Model: ❑ Tnnk Overfill t lligh-Level Sensor. Madel: U Trink Overfill/I ligh-level Senear. Model: ❑ tither(specify ui trent type and strudel in Section 1°un I'a c 2), U Utirer a ecif el ui Irtertl type and model In Section E on Papte 2), Dispewer It): 1�C- F )0-A g ):, >Dr>r C) Dampen.<rr Ill: c% e;'i �1 v7' ;y-• "T %-!1- U T %-!1-U Diapensrrf'nnta'rnmrnlSrusor(s). Model- R-0 -a® _ U itiapetim CowninitirpilSrnsrn(s). KOH: 19147 VP".-its" U Shear Valve(s). U Slim Vnlvefs), Q Dispenser Containment FloaC(s)and Chnin(s), U Dispenser Containrncnt Floats and C}rain t+ , Dlsr^r,riser 11): Dispenser Ill: L1 Dispenser Dispenser Containment Sensor(s). Mnrlel:_225�� j--Ppz- U Dispenser Conininmenl Seism(s). Model: ❑ Shear Valve(s). U Shenr Valve(s). ILI Dis nser Containment Float(s)and Chain(s). U Dispenser Containment nuat s and Chain a , Dispenser ID: _ _ _. . . . 111spemer Il): ` U Dispenser Containment Scmor(s). Madel:--._-._..- .. ... _ U ilii lrenrter["ontoiurrtrnt Settsar(s). Model: ❑ Shear Valve(s). U Shear Valve("). UDispenser Cuntaitunent Floats and Chain(s). U Dispenser Conininmetlt Float 9 and Chain (s). •If fire facility conftiins ern+te tanks rte rlispcnsrrs,espy kris f+nen Include hifnrmalion for every tank and dispenser of the facility, C. Cerflnenlit)11 -1 certify Iha1 the rtlnlintwitt h)rntffird In Ihls dnrinrrrrrl was lrrsprrtrrl/servicerl In tircordaince wilh the Imanutactmnmr' guidelines. Attaches) to this Certification is Informallnn (e.g. ninomfacinrera' clrecklls(x) necewsnry to verity that this Information is cvrrerl Find a Plot flan ahowlng the layout or nrnnlloring rFlOprrrrnt. For tiny eynilnrrent rrrpame orgenera(ing Inrch repor%I hove alga alfit rhed a ropy of Ilrr report;(rhe r all fherrn/+rlr): U Svntrnr MCI-op U Allis 11 Irltitlrry;report Technicino Nnmr(prim): rr.o Sip;lrrtlrrrc: t hr l Gc�ca° ..e Cerlificnlimi No.: �6_0 i irvrtsr Nw- 1'nRr f of 1 03101 Monffurirrl? S}'Stettt f'erlltirnllnrt