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09/26/2002 14:42 FAX 425 251 8782 BARGRAUSEN 0 009 l-7 IIIR IN5P6Cl'ON y IPE INPAGE 02 09/17/2002 15:55 523 ' -ZAf;I,..I&K.Pr,7pNftP-M $'op-Y7-O� Q :OgP stroVpo pta ro7QVm main{ 707 577 0586 P-04 MONITORING SYSTIEM CERTIFICATION O'W rola Code af Rrowlarions ArthorCoda 7y Cued: Chapter 6.1, Health and 5443Y Chapter/6, 01wwon 3, Tide 27, Cdl{ja __:5,_,.�n.er rehaM1 nlh8l be or si This fotur must be uaed to dpcumont wsdng andµd""'118 of mon toting equipmen[. +y Nls frntet meet be plgivided w the tank ti g y�atea� enol oenel by tat twhaician w�yedorim the work, A COP uf re Matin UST a Berms within 30 systan owoor/epuater. "l'6e oumerloper&=sanest submit n of this form to the local nCY B B Y days of fat data. A. Geaeral information R rG Sldg,Nc.: Facility Nash: 01. tJ 3-77 Site Addrrss: a�. +=--is�COwT 4,i otC City:r r{rLG Zip:.. Facility Contact Parsoa: X r,s�s'� Contact Phone No-: �r (� _ Date ofTestinglSery-tiny: .�J_J-/ QZ MakrMode)of Moruwring SYNI= B. IayaDtDiry of Equipment Te6tetl/Certlfled Caedt rtw Nasty to and . Ian stared: Tao)t[D: T}.U?: �u•Twk Gaaatns Robe. Mohd' Gln-T.n1c G+u4icy probe, Moder Amulu Spew of Vaa samot. Model. _ Q(AMW"Sgoe or Vault Scmor. Model'. kplptay 54mp/74mrh SaasoKs)- Medd, ping Sump I ar(t). Samor(c)- Modcl: - Ift,Fiu Sl asp Bcswds). Model: Pd{Bump Beaatu(e). Model' 7 2 S .�3 6 Mrshaoieal Lix IA"pefectrr. Mode:i 0 Merlomlcat QIm Leak Ddectnr. Mudd: OP Iiw l4dt Detaeror. Model:�-��p�-�— O t]aGttanlC Idne Ixok Detector. Model; Tank Of MI'l high-Level Season Model:J_tr l.�--- ��p�fil]/Nt¢h-IrvW Scorer. �J Omet s I anent -SLA to Stearin&tan a Y Q Drher(s a' a ui 1Tent and model to 9eaim H as 2). Trak nit Tadsu)l i►Fo-Tuk 6+tVPR Abu. Model• �� ❑ 1nrCank GwttnE Probe. Model: !(Annul,Spar w Vault Seiner. Medrl, (� ArAWDspssaar Vault Semen. Modal: L'L Piping$ttmpl Ttoorn 5ensoKs). Modal: 9 p Piping Sump/'hetah ScneoKa). Model; t(5,Pill Sow Saaear(s,. Model: O yn Briny 8ontor(r). Muriel: Q M cuff"lane Loa Derewr. Madel: O Mechanical Line leak Dewtor. Muriel: ❑ aired Lus Iesk OdwwrMudd: O Electronic Line idk Detector. Model: X-Tank R'trtui r tligb•Lsvel Sensor. Model O Tank Overfitl r lflsh-l<val Seem, Model: O Otho s W rneht and model In Secdan Hoa 2i, f]Oinge a of ui men[ and modal in Serttoh B on Po a z). pispeaaer IDs DtapameR IR�} N ---�74A �- I�bfapcverCanmi4—N,ensoKe➢. Model' Diapaaear Canlafmmcet e;. Medal: 71;. goi2_-_ Sher Va)vep), 6hear Volva(s). O neer Coaulemeht s and CbW e. O Aix Asti Conahvxot Flo sand Cast t. D1Y ,3Cb spen....Caa[ainmaoc 9ensoRr), Mode= Dloponsu Coptdptn.'nt Suesorts). Modell O I�Sbaar Valwe(e). ar Valwc(s)- ❑ Dlf til Conlainmaht Flow,6s and Ctuln a. t7 Dia peer Containment Pleat u and CNaln(s. DYepersser ID Dlapansa ID: A mpmstr Conw,awst Senear). Model: i apcwer Conetuement 5amor(a). Model: herr VaWs(e), 0hear Votwe(e)- CIDia Containment Fluas(r and Chem s'. O see Contvnmont Plnol a and Chwn s. -It the facility tamnlm Moro tauka ar diapaatras,Copy thiC term. include ud'ormaurm for every task and dispenser at the fewilltY, C. tbrllQCcilloA•I aar{ity that the tgsslpmttnt Idaotlfled to t1sL doewnent waa INpsreodla.ntced W tt¢asdaoae slid th.rustutaetures5' htddebnea Attached a tide Cartllkm lm b iafnramrlm(a.s. msmeficwrwra` choddists) nteweary to rarefy that WE mlomtautm b mrrad m7 a Plot P1ten abowing the layout of modaorMe eVp�L For any■ W moat Capable of gemratlny eirob reaw ports,i h -ew atfadted a COPY a the tfpattl(Cheek all mat app it yeteru sv,. p m iiwsory report Twhnici a a Kam(prin* e. ew L- Signal CENfication Nn" 543 - -1 - G0 C- ifLitanw-No,t 3 u - SffOl ACfCaLt n wt � rs phone No. { tVZ ) 77' 73Cr7 Tratiog Company Name:.__ Site Adtticse:3 :_nr?6 L"e�� fin- c"�VT- •-L-L- - Date ot'I'esbng/Serv�csn`: vn.ut 1/s PaQs7 of sew.aHelfdl www.0 W dw ary