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07/21/2008 15:41 FAX 10006 MOi` CERI'i1'il I C A'11't<d. N lin (%er BI-.110arlsi ielinix Il llhin lhr Slaw a/'('u i irrnirr .tudwrimCalert:<'hrlpnrrA7. lhwhhretrl, glJJvCmAl. (Aipler l/t l)ivirirm.i, Dili- C'dlOolma( ode u�ld:)prLrlinl6 'I his linin iuml, he used Iu dneialt1111 lemliig and scivicill.. of wugilmiutt eeplipn,enl. 6. 1&parmte ccrliLcatinn or rwoit nwzl he >UeEiLre;A lin catch uwniturin; system L nIroI I(_aliel by Iiia Iechaieiwl who perfernil the work. A copy nfrhi;IbI III must he provided to the tank \yslail owiar/operator. The owner/opemlor most submit a copy of thin fixill 16 the meal a);eIICy MgUla(ing UST systems Within 10 clays ultcsl dib:. A. CJeneral I111`nrunllion ` -- Facility Name: .., ... ( (,Asn;l ' (_)r.> i I{Id,.a,. No.: L_. Site Address: 2L� .�)1 4� }\v.)1�. .., City:�CGw n. ........_. Zip: ZZ�� — - Facili(yCunlactPerson: r',Lly(,fI _ ... ConmetPhone No.: (�.Q;� Make/Model of Monitoring System: �('.t''i?�,k� 1-?f>(7{ i_ .`�� s(J _._ Date of estini/Se vicing: ( /Cl._'+!r), i•,_ B. Inventory of Equipment Tested/Certified C1crh rbc n 1 m rime boxes to indicate s Ierifir er ai wu!nt ins eckA/snvirrd: Tank 11):_.. DTank ID;... ...._.. _ lu=Yank Gauging P,ots.. Model: C- k1i) ... U li-Tlmk Gmugine,frolic. Mudd: _ Annuhn Space fir Vurdl Sensor, Model: l f 7!T Q Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model:_ Z(Z U Piping Saw /Trench Seusul(s). Model: Q bill Sump Sensor(s). Model: Q FIII Sump Scnsor(s). Model: L/Mechanical Line Leak Detector. Model:1_>) ZUGK?_.__ C1 Mechanical Line Leak])elector. Model: Cl Electronic 1,Ane Luck Detector. Model: ._ U Electronic line Leak Detector. Model: C) '1':Ink Overfill/Iligh-Level Sensor. Modrh Q '1 auk Overfill/High-Level Sensor. Model: _.—....._ U Olhed (specify equipment type and oludel iu Seclilm L:m,Page 2). U Other(speciF c ui nnunt IYN and model in Section I'f on Page 2). Tank Ill: _ Tank ID: U ht-Tank Gauging Probe. Model: Q In-lank Gau)ting Probe. Model: _ U Annular Space or Vault Sensor. Model:._ U Annular Space..or Vauft,Smmr. model: Q Piping Sump/Trench Sensm'(s). Model: ..- _ ❑ Piping Sump/Tmuch Sensor(s). Model: ❑ FAII Suuap SUILWI(a), Model: U FAIT Sump Scnsor(s). Model: U Mechnnical Linc Lcnk])ctector. Model: U Mechanical Line Leak DULcun. Model: U f lecbxmlic Line Leak Detector. Model: U Eleummmic Linc Lcnk Detuclor. Model: ❑ Tank Overfill/Iligh-Levcl Sensur. Mudel: ❑ Tunk Uvcrfill/Iligh-Levet Sensor. Mtxlel: Q Other(s ecl' cul ment ty a mad model An SUcliuu E un Pace 2). Q Other(s)ecily m it: mcnl l e noel mo(Irl In SCCllo11 E un Piµc 2). Dispenser ID: '� t I�,) Dispenser 11):._. 1�J + 1 ,,, U Dispenser Containment Sensor(,). Model: Tole) Q Diapcoser Containment Scnsons). Model; 7Cr4`5 U Shenr Wdve(s), U Shear Valve(s). ❑ Pislx:nscr Confninmant bloaL(s)and Chain(s). _ 13 Dispenser Containment Moans)and C.'Itain(s), Dispenser ID; I s I z Dispenser ID: U Dirprmser Culllanllneul Seusnr(s). Mndcl: 70b. U Dispenser('Omailatll'I)L$CIISJr($). Mrx1eL'_.._,_ Cl Shear Valvc(s). Q Shem Vulvc(s). U DAs sneer Coll,Anment flo;il(s)and Chain(s). Q Dis cnscr Containment Float(O and ChuinO). ,.,... Divpen 1216 f ' C Dispenser 11); ... Cl Dispcltsrr Conhlinment SclisoL'(s). Model: L!;;?-_ ❑ Dispenser C'mntainmrnf Sensnr(s1. Model:_ ,. .._.. U Shearvalve(s). U Shear Vulve(s), Obis msar Conlainnlcnl Ftoat(s)and Cliai)(s). ❑ Dis)ensei Containment Fluul(s)and Chain(s). •If the lilcilily u)ntains altos talks ar di.epenscrs,ropy this limn. Include Anfmv�lupylion fur every tank nd dispe s'r al Ihr limyl ily hT �yr'tntf �� C. Certification - 1 certify that the equipment id enlificd in f + tloempc'1 �: 7ns rccictllse�rvi�e iu Ikecnrdanec With the manufacturers' guidelines. Attached to this Certification is information (e.e, manufacturers' chocklims) necessary to verify Ileal this hif irmalinn is correct:md a Plot Plan shuwinp (tic layout fir mnnituring equipment. Icor any n t 1micnt capable of);enena(Pn(;such reports,1 Iwve also all I •.P a copy of the report:(rherk all and apply): s s sr rs ,ply rm hhgfot;y report '1'echnicianNzlme(prinp: _u * lll.)o _ Signanu•e:, I' 'I-i _n„cs/� . CcrlilwnulioNo.:,, _r J Licensc.No.: Testing Company Name: rDN 'TegT ...__--. . .._ Phone No. 6401 I Ali 'l C r^ c Site A(IAa'ess: Page 1 of 113/01 Il'luniloring System Cerfifiviltioll D. Results of Tesling/Servicing