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` fxbar C` . ��yFaL� -/-- �s� r <br /> �p �f(Jf�t'1E'trl hl1, <br /> •Qrinf.nl•rr:.vnNr. lir• 1)nmr•/rr,/rOnNn �;fNa•.cnrnrrnxnn/f/.,pg. s' pp 44 <br /> PM <br /> Pos! Ojflce flax -16 Thornton, Ca. 95686 (109) 794-0102 Fit X 7Y4-00 1 r <br /> General Informnlion L " <br /> Facility Name: )5 JT �1-`�('�e 1 <br /> Bldg. Nn.:_ <br /> Site Address: ___7-41?___7-41?__'� I t'. Cily: "'r �/T01, 0 a Zip: 0,1— <br /> Facility Contact Person: Day f �+Conlan !'hoar Nn.• <br /> Make/Modrl of Mnnilrn ing Syslrnr rLv a aJi2 )049 l I gtlr•.d '1 i•stin)!/Ser win{!: G h�3 /03 <br /> IL invertlury of hqulpna'nl 'Ursled// 'el lilir•rl <br /> (beck the appropriate boxes to Indicate a telae equipment het rerledhel wired: <br /> Tank IU ' <br /> I suit11: <br /> U IwTank Gnnging Probe. kindrl' 'nnk(inoging Probe. Model: <br /> U Annular Spare or Vault Semot. MaJrl: U L..9 / /n inr SPnre ur Vault Sensnr, Model: Le /L S <br /> U Piping Sump/Trench Sensnr($). MndrL' _l.(h S g finny/'I'rrnrh Sensor(s). Model: Lr !.. S <br /> U FII Sump Setnnr(e). Mrvlrl' olop Srnsnr(nl. Mralel: <br /> U Mechanical Lire I"Ir I Trim-fol. Madel: n tical I.Ine 1 enk 1)rlermr. movie[: <br /> ❑ Eletlronic Line Leak Detector. Model. undc Line Leak Detector. Model: <br /> U Tank Overran/lldghA,vel Senear. Modrlt . Overfill/Illglrl-evel Sensor. Madel: <br /> ❑ OIliac(specify equipment t and model in Section E on Page 2). r a ecif ul meal t and model in Section E on P e 2 . <br /> Tank ID: -__ Tank ID: <br /> U In-Tank Gauging Probe. Model, U In--'tank Gnnging Probe. Model:_ <br /> ❑ Annular Spare or Vault Sensor. Model. U Annular Space it Vault Sensor. Madel: <br /> U Piping Sump/Trench Sensor($). Model: U Piping Sump/Trench Senmut s). Model: <br /> U Fill Sump Sensor(s). Malrl: U fill Sump Sensntlsl. Model:_ <br /> U Mechanical Line Lenk Detector. Model: U Mechanical Line i enk Detertur. Model:_ <br /> U Elecimnic Line Leek Detector. Model: U Electronic Line Leak leteclor. Madel: <br /> ❑ Tank Overfill/lligh-Level Sensor. Model- U Tank Overfill/I ligh-I evel Sensor. Model: <br /> U 011ier(specify ui nen!type and model in Section L•on Page 2). U Other s ecif a vi meal t end ulralel In Section E on Pa 2). <br /> Dispenser III: / 1`---2-- Dispenser 11): _ 3 y"H <br /> U Dispenser Comniontent Srnaotlnl. Mnlrl' _ M 1- S U Itispenser Containment Sr91a111($). , model:_- "A. S <br /> O Shear Vnive(s). U Shen Vnive(s), <br /> U Dispenser Containment Float(s)and Chain(s). U Dispenser Conlainmenl Floats and Clain s . <br /> Disperser iD: _ „ _ Dispenser 111: <br /> U Dispenser Containment Sensur(s). Model:_ U Dispenser Containment Sensar(s). Model: <br /> U Shear Velve(s). U Shear Valve(a). <br /> U Dispenser Conlainmenl Floats)slid Oinin(s). U Diffpcnseir Containment floats and Chain(s). <br /> DLepeeser ID: _.__._-.. . . Dispenser DD: ' <br /> U Dispenser Conlainmenl Sensor(s). Model:- - __._. _ U Uis(renner Cnntninmm�t Sensor(n). Model: <br /> U Shear Valve($). U Shenr valve(s). <br /> UDispenseir Containment Monts slid Chain (s). U Dispenser Containment Float(s) and Chain(s). <br /> •1f the facility contains tone tanks or dispensers,copy This for lir Include infnnnalion far every inuk and dispenser at the(wilily. <br /> C. CerlUlca(loll -1 certify that the ayolpnlrnt Idrnllard In!his dornolrnl was hope I"Nervicerl In accordance with the nis sNhMurm, <br /> gulddhles. Attached to this Certification Is Inimonaliml (e.g. ma infoclnrers' checklists) necessary M verify that ibis hlformUan Is <br /> correct and a Plat Plan showing the layout of mnnllrrrhlg equips end. For any egnlpnrenl capable of Renerat hR such_•reparts,1 have alae <br /> attached a copy of the repru71(rh rA nit rhos I U System mel-up U A J!�Y'm or rep�wl <br /> reclodcintl Name(prinl): /`L1/ /7/l/ (G/!iC!'S Signmtnc: '¢rp,,-••I'P„/ �d° fl.�"' -;�" "•� <br /> ,ertifiralion No.: 0004 0r3 I.ir .",e No.' <br /> i'nRe 1 of 1 03/01 <br /> donllorbrR System CerllDrnUnn <br />