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Af fjarb x t`�. e'# AlM01 lnntnT7rS'T/Nor 1; IW1?F1?G/fnnNf) 7AArKc,(rnrrr)►tvn/f/.E§WMNMSNTHEAL, i Poll Office 13or 3f; 7bunrforr, ( 'rr. 95lr8fi PERMIT/ ERVI(' c /h (209) 794-0102 rAX 794-012 r General it oritialion rncdlity Name: D Q` tae u a( Bldg. No.:____ Site Address: _ I T OC d Q 1^ ev Cily: ioL a F l)r fl y ) C ori, 7.dp: rarildty Conflict Person: 6 y f•4 t'onlnr•f 1'hrmr No,:( Z09 ) �'�"'1�� Make/Modrl fir Monitadng Syslrnr 6r t-14 4f)040— Ihrlr•nl 'll•slin)!/Seo virinF:�'J /�fS/�T_ Ii. Invenlnry (or Ir:gndpnn•nl 'Tested/1 'erfilied Oteck the appropriate bootee to Indicate specific etrulooment Ins reclrd/err viced: j I Tank ID: is l.. 'Tank 11): _ �7 N O In-Tank Galrging Probe. Mold: Or U In 'Tank Owning Probe. Model: k ❑ Annaler Space or Vault Sensor. Model: t p U Armorial Spare or Vault Salvor. Model: Wiping Sump/french Senitor(o). Mrnlrl: 9001"-'5$0-> O/r UPiping Sump/'1'rrndo Sensnrfs). Model: —7-C' U Pill Sump Sensnr(a). Mrelrl• U Pill Suugr Senarn(n). Mrnlel: U Mechanical Lire I enk I srierim. Model: On p gl.oho.�,o a Mrt-brouicorl Lire I enk Deler .lor. Model: O Electronic Line Leak Defector. Model: U Plecuunlc Line Leak Detector. Model: U Tank Overfill n ll/iligh-1 evel Sensor. Mdcl: U 'Tank Overfill/high-level Sensor. Model: O Utter(s if ui nt t and model in Section E an prone 2). U Utter a ecif ul meat t and model in Section E on P 2). Tank ID: li 'Tank 111• .fl %s_ A In-Tank Cauging Probe. Madel: N•/a 4 U In=I'onk Cnnging Pmlre. Model: !M 4 rot O Annular Spam or Vault Serrano. Moalel! U Annular Space nr Vault Senator. Madel: U Piping Sump/Trench Senaor(s). Molel:. 7AN 1�SfQ1/KL U Piping Sunryr/Tlenrlr Sensorial. Mullet: O rill Snngr Sensoria). Model: U boil Surrgo Serfaor(s). Madel:_ Jk Mechanical line Lenk Detector. MonlrL• X tA-Mechanical Line 1 enk Derecktor. Model: U Electronic Une Leek Detector. model: U P.Iectronic Line Leak Detector. Madel: U Tank Overfill/high-Level Sennnr. Madel: U Tank Overfill/Iligh-1 evel Senator. Model: U Qher Ciptocity equipment type and model In Section L'oro page 2). U Other(specify a ui meat 1 and model in Section Bon Pane 2). DHpenxr 111: Ildeperser III: / U Dispenser Containment Sruffo ). Mrnidt >•H3 av U Diapruser Cantadnnmd Semaor(s). Male 1: U Shear Velve(s). U Shear Valve(s). O Dispenser Containment hloal a aid Chain(s). U Dispenser Containment noti and Amin c. Disperser ID: /, .__ Dispenser ID: .. / /_ ;A1 0 Dispenser Containment Semor(s). Mndrl:. 7 4,�✓'$.�?'?Q�_ U 1.)iepenser CtmtainnKnl Sensoria). Model: 74,,14 wXW47 o'1.9 ❑ Simar Valve(a). U Shear Velvets). 1U Dispenser Containment non s)and Chnin(s). U Dispenser Containment Float(o)and C'bain a. DlsperserlD: __._-.. . _ Ilinpemnrli): ' 0DIsponsuContainmetitS=MF(g). Madel: -........ . .-.._ _ U Ulnpenaer Con lainnient Semor(a). Muriel: ❑ Sheer V alve(s). U Sheer Velve(a). Mia ser Couledntnent Float a and Chain(s). U Dispenser Containment Flotilla)and Chablis). *If the facility contains franc tanks or dispensers,copy this runt. Include information fm every tank and dispenser at the facility. C. Cerliricallllil -i certify that the equipollent Idenlinefl ht thin dorcnuwnf was In+perlrtVaervlced ler accordance with the manufacturers' guidelines. Attached to this Certification Is Inrnnsrnllon (e.g. manufechtrera' checkllata) neemary to verify that this information la correct and a Plnf Plan allowing the layout or monitordng equipment. For any equipment rapalrle or generating well reports,1 have oho x1fi ched a copy ar the •rehrea orf r npp10! U.Syalem lel-up L) .in in orr J orl Native Technician Nae(print):�N 4zf A�11"" Signnnne: L> �,�Gfd.4 Cerliffralion No.: $/�✓/G2•r�hOt� I.irrnsr Na.: Page 1 for 1 03/01 1lonllnring System Certification