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a14 R-73 f farba,.- �N/ UTY 7rs7ING(N;.UN1)f.1?(; 0 1N1) 7ANA',V A7'Al-,TVI?IJA Lrl?Arrs, i Post 4ffice l3o_r 36 7lrvrntnrr, ("r1, 9566 (209) 794-0102 EA.3C 794-0112 Genera! infOrn) lime Facility Nan(e: _ j1 r�c3! + �'�1 y- } t?/ filclR. P!r►.: Site Address: d �4 fit.r'U J (/!'G�' Cit k �t r p - Facility Coninct f ersow ... C(mincl Plmrl(• No. ----- MnkelModel of Monilorio,g 5ystro(:�t,f�L��-C�l+ �f1+1�, rTnlr•rrf 'I cstirl}!ffirrvicinl;: .7._1�vRl�� I3. 1t)venlr►Ty (rf Eyni�)ntcnl •f•CStE'II/l•i`r-Iilll`ii Check(be appropriate boxes to Indicate s eclnc equip men(Ins rerted/serviced: Tank ID: _ _ _ - -- 'Tank ll):_ _-- Url-n-'Tank Gnuging Probe. Nlmlel:_ Ly'FI-Tnnk Ganging Prole. Model:_ 97Conuiar Space or Vrttfi-SrewFwr. M(rdcf:( Oo I1yYDDP [TAmmlar Space or Vnull Sensor, Model: U T'iping Sump I Tom). Morin: P/�V:. CCVW Q U- iping Sump I"Frrneliriersscu(g). Model:V41&a3 OFLVP61 ❑ mill Sump Seotor(s). MndrL' U fill Surul,Srusm(q). M(ulel:_ ...... UMechanieal Line I.enk l)rlrclnr. Modrl LT'Pechnnical Linc l eek I)Nrclor. Model: ❑ Eletlranic Line Leak I)etect(ir. Mndcl _ U Electmidc line Leek Delector. Mrxlel: ❑ Tank Overfill/high-I.,evel Sensor. Model:_ _ U 'Tnnk Overfrll/I figh-Level Sensor- Madel: ❑ Other(s ecif Equipment t1pe and model in Section Fun iv'ie 2 U Other(specify ui ment type and modal in Section E on Ps e 2). Tnnk If): e- __ ____ _ Tnnk[D- EM-Tank Gauging Probe. Mo(IcL'— _ __ U In-'Tank Umrging Probe. Model: EY'Annnlar Space or Vault Sensor. Model: P p 6�j f t7�� LI Annular Space or Vault Sensor. Madel: ['!'Piping Sump 1T�.ru(s). Model:f[ b�'50-700CDIr: U Piping Slump l Trench Sensor(q). Model: ❑ Fill Sump Semor(s). modrl.. U frill Sump Srimmis). Model: O'rvlechanical Line Leak Deleclor. Model _., _ U Mechnnical Line leak Delector. Mtr(I[I: ❑ Electronic Line beak Detector. Model!- U Fieclronic Line Leak Delector. Model: ❑ Tank Overfill 1 high-Level Sensor. Mndcl:.-_ -_ __ U 'Tnnk Overfill I Iligh-bevel Sensor. Model: • U Other(a ccifequipTnent type and model in Section E un Pae 2). U Other(Specify u ui rrrenl type and inodel in Section Eon Palte 2). Dispenser 11): /I V_ -_-_ _ - _ - I)IRpemer 11):. __ '-V--'�__— ❑ Ilixpenser Containment Sensor(s). KOH- U I)IRlrrnscr('onlninrnrnl 4rmsnl(s). model. ❑ Shear Valve(s). U Shear Valve(s). B'Vispenser Containment Floats and Chnin(s). (I'Dis nser Containment nont(s and Chains . Dispenser 11): 5:t_ 1. ---- - - _ Dispenser ID:_ 7 Y_ A-- --- -- ❑ Dispenser Containment Sensor(s). Mnrlrl:______ U I)ispenser Conlainment Scissor(:). Model: ❑ Shear VRlve(s). U Shear Valve(s). 93-Dispenser Containment Float(s)and Chain(s). W-Dispenser Containment float(!j and Chain (s). lVispenser JR_ /Q . __ __ Dispenser ill: // J;z ❑ Dispenser Containment Sensor(s). Model: . U DispenserContninmenl Scnsor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). Wffispenser Containment Floats and Chains . UrDispenser Cuntainlnenl Float(s)and Chain (s). off the facility contains more tanks or dispensers,ropy thir forlrl. Include information for every tank and dispenser at the facility. C. Cerlificallon -I certify that the egnlpetwill ldcnllfled In this d(knrrxmt waq htspecterURervice l In accordance witii the nonufacturen' guldellnes. Attached to this Cerlincatlrrn is Information (e.a. manufacturers' checklists) necessary to verify that this information b correct and a Plnt Plan Rhowing the Inyont of mnnllming erinipineni. For any equlirnrenl rapnhle of generating atich reports,I have also attached n copy of the report;(r, n herk all Thal n�rrpr r): U Syslcnr Ret-rip U A oil 10510 (report Technician Narllc(print): l e N I Cerlif3rnlion No.: I.irv•nsr Nn. TtTestingf`nm)�any Name: f f L°<i/ -/7-j✓�r I'lmne No.1 V e)fI -29 rage I ..(� parol Mtmltoring System Certification