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l f orbraAT <br /> jeR <br /> 'Qf/AL17T•7 F.S77N(7(IF f'NI IFR(7R(If IND) 7ANR.4 A7'ArFOROARLF RATPSr <br /> Post Office Box 36 Thornton, Ca. 95686 (209) 794-0/02 FA,K 794-0112 <br /> It' neral IntDrmallo° Rldg. Nn.:Name: 1� 0 OA <br /> Site Address: <br /> p� Cily' � dip-' zip: -& M <br /> Facility Contact Personkf/hTI'k <br /> cmonrt Plane N,r. y <br /> p� 7—a ilk G- u 4, r�f I tntr at 'I elling/Crrvicing: �tl l " <br /> Make/Model of Mnnilon ing Sy.clrm:�//� <br /> Ii. Invenlsny of I:qulpmenl 'I'esl[d/l'erlllird <br /> Cloth IM approporiste Man to 1 Imola @Ptctnc ul men/los ected/ser cicedi <br /> Teak ID: Took ID: <br /> O In-Tank Onuging Probe. - - Model. U hrl nnk Clanging Rohe. Model: <br /> O�nna6r S ace a Vnnh Senior. Model: r��,�ja+GEv ')$'� U Anular Space or Vnull Sensor. Model: <br /> arpiping Sump VRelseMSenano(9). Model:F Baov ,,•p- 9$�(eflj W51ping Sump/7^nllahFfll9$wrtla). Mendel v <br /> O Pill Sump Senson(a)- M,alrl. U Pill Suuq,Sntnnrls). MoskL•_ ._.. <br /> O Mechanical Line leak Itetectnr. ModelU Meclankel Line Ienk Detector. Madel: <br /> O Mectmnic Une Lank Detector. Model:--_ _ _ U Electronic Une talk Detector. Model: <br /> O Tank Overfill/High-Level Sensor. Modem — _ _ ..__ .._ U 'rank Overfill/111811-level Sensor. Model• <br /> O Odw 1 ui nt t and model in Section E on Pae 21. U Other(specify of t t and nhodd U Seeding B w Z <br /> Task IDs __ _ _ Tank ID: <br /> O In-Took(holing Probe. Model. __ U In=Tank Oonging Probe. Model: <br /> U Annular Space or Vault Sensor. Madel -_ U Annular Space or V @Ut Sensor. Model: <br /> U Piping Sump/Trench Sensnr(s). Model: U Piping Sump/'french Sensor(@). Model: <br /> O Fill Sump Sensor($). Madel: U Pill Sump Sensor(@). Model: <br /> U Mechanical Line Leek Detector. MIArl U Mechanical Une 1 eek Detector. Mudd: <br /> O Mecuonic Une Leek[elector. Madel: U Plectmnic Line Leek Detector. Model: <br /> O Tank Overfill/Iligh-Level Senear. Model: _ _ - __ _ U '1'soft Overfill/Iligh-level S[nno. Model: <br /> ❑Other(spedty-equipment type and model in Section E on Page 2). U (Oder(Welify equipmenj type and model in Section Baa <br /> Dloperaer ID; _...__ -- _ -. Dlgwmrr 111:. -- <br /> O Itspenaer('omalnilrnt Srroohlnl. M,vIrl, U Dispenser('ronalnuwnt Rn1unU). Mokl:_- <br /> O Sher Valve($). U Shen Valve(%). <br /> O Dispenser Containment Float(s)and CTudo(s). U Dior as Containment flout(s) aid Chain(s). <br /> DYpener ID: _ Dispewer ID: <br /> O Dignrner Containment Sensor(s). Model' U Dispenser Containment Sensor(s) Model: <br /> O Shear Valve(s). O Shear Volve(s). <br /> O Dispenser Containment Float(s)and Chain(s). U Di sir Containment Float(s)aid Chains. <br /> D�ID. Dlapesaner 111: <br /> ODispenserConuinrnentSensor(s). Model:_.___.__. ._ ____—_ U Dispenser Containment Sensorial. Maki: <br /> O Shear Valve(@). U Shear VRlve(s). <br /> O Containment Floats and Chain (s). U Dla ser Containment floats and a . <br /> elf the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the Witty. <br /> C. Cer(incaUon -I certify that the equipment IIIc1111Ee11 III IIIH dmonvent was InspectrN@erviced In accordance with die g000b lORW <br /> gold nes. Attached to this Certification In Information (e.g. mannfacleren' eheeklitls) necessary to very) Ilial Ni lda lmWIM IN <br /> certM and a PIM Plan showing the laymot of monitoring egnipmenl. For any egnslpnwM capable or lenerNklg well n*artfr 1 honor dw <br /> attached a copy of the Tel-(thee off that applyR U System Pei-lip U A r lis eport <br /> Technician Nerrhe(print):_� �`P. s��fe'rO' Sigunmre: �rX 7 tic.-. <br /> Certification No.: _ _ G©tSr I.uric, N,, L17—//yam <br /> Testing Conpnoy Nno e:/9 9GP1tJ<CV7;_;,1 _ Phone Nn.: wc� _.) <br /> I'"Re I .,f 1 alsll <br /> Monitorhtg System('ertifienfinn <br />