Laserfiche WebLink
u0: ova rrT T ur'aa— t V71L, aCUaJ fav—U11C w, p <br /> .orb l <br /> .�1-1n/ OOS <br /> 0 <br /> 0 <br /> Post 0fce Box 36 Thornton, Com. 95686 (261) 714-0102 FAX'.'"=fit12 <br /> Grenelral Information <br /> Facility Name; F • F� Yv1 o t�T �c�ti,C o r.� _ Bldg. No.:— <br /> Sitc Addmrs: Z 1 S$ E �_ F2E kYltata-� ,5T <br /> - _.�.._ --- - -- �.ity: _ .17UC_.1�,=•rte�-- _ Zip: `1520 Z <br /> Facility CtetttaCe Pcrst�n: LPL. <br /> Makr/McxJcl of Mottittning Sysu m: iZOu'"T S -7 S{, Daw of Tcsnng/!Servicing: <br /> B. inventory of Equipment Tested/Certifed � - <br /> C'Y"k the=priste bolus to indirate 6 antic equi went ins ected(vrrvtcc<l: <br /> r/zllul2r <br /> KD.Tank Gauging F'rohr. McKlot - ��i T 3 �' t Z— VnIk <br /> ) ni.Gat,sing Pr< e.Space nr Vault Smvim, Model:_m_ [�Gr -- <br /> p 1 ar Spare or Vcult$%arse% Model: 5 Lt-rvrE a Npiping Suallp/Trench Sensor(,,). Model' � � U Z��> Sump r Trrnch Scnsor(s) Model:Keehunicid <br /> SumpSrrlsnr(s). 34Ls urer S,:ncnti j. Model: ��' <br /> Line.Leak Dctectxrr, Model:-Cr E%t—, K! MC.heTJCrll].ane Irak De,,&cror_ Model: _ is <br /> U Electronic Uric Leak Detecuw, Model:_ (❑ Ele::trzmic L na Lc:,1 T�ctcctor. -Model: <br /> ❑ Tank Overfill I High-Level Sensor. Model: L7 Tank OvtTfil:;High-LcvrJ'-cwjr, MI CKic1:_ -- <br /> {}4cr(,Vmieipilinwrit tyjy ilm nvvlrl in Sc'114n C inn Pupa t) 2 (hher(t mit .a, A - .aual rrua.iel In Se-et17n L t,., <br /> T nk ID• 9 1 _ _ Tank ID: <br /> In-Tank Gauging Probe. Model: />7 Q / ❑ In-Tank Caul;ina Probe.- Model; - <br /> ❑ Annular Space or Vault Sensor. Modo1; _ 5<`—f_ TAN_%L p on lar yFg•e or VNalt �r.nsor. lviodel:� - <br /> Piping Sump/Truic.�h Sensor(s). Model:�9'-/�^� 2c"t, ❑ Pi it <br /> g Sump/Trench Schsc rws Model. 1 <br /> Fill Sump Sensor(s). Moticl: 2iZ3�- Zc, , J Fr 1 Sump Sc:)sor(s). Model; ' --_-- <br /> Mecha,ticul Linc Leak Detector. Model:_ pe l rLe� ❑ echoer^ ',i ine L.ettk ctor, Mudd;_i <br /> (lJ Electronic Line I=&Dewror. Model:. i� ❑ lu a�ttsc L;is lrxk Octtccto�r Moael / f <br /> C] sfi <br /> Tank Ovll/High-Level Sensor. Mexlcl: _ :J Itut�(Nerfili/p{igh-iJ v TS-n,or. MtxW; <br /> ❑ Other(rpacify ui mora typc and model in Src:tion E on Pa'c 2). ❑ C)thor Le U il' equiLnwnt type an(".model in Section E on Page 2). <br /> )DIS neer M: Z _ D t�r�er TD 7if�— �. <br /> trierlSrt Crsttiei�K u:Scu�ur(a). Mrtdd; '�`�O-ZoS� pispen,,Q C:c,atainatene Snns�r(s). Mnclel;_ �'�0 <br /> AEr Shear Vulvp(t), shear Vmlve{.j. <br /> ❑ I>isponser Conwinrnont 1`7ot(S)aril C:haain(s). ❑ Ditncn.ccr Cc.ltainmcw Flost(s)and(hnin(s). <br /> Itis ttacl ID: -14Dber ID: _ <br /> ispenserConwiamcntSeiler(~). NJ 110DispenverCc,tw,nmcnt5en <br /> Shear Valve(s). C) Shear V dve(.:). / <br /> Q Di.¢nenter Containment)rinat(s)urn]Chain(s . ❑ I3is nwr Co))taanment FIOVt ,)Lnd C:haia(5). <br /> 7s)14:1 <br /> Dispery;ir 1D!seeContainmentSengur(v). Model:� ` �-�G S L1 Djx`pcnsar Cone iL nmc Se lwalve(s) <br /> ❑Dieft^nser CWtainmew Platt(s)and Chains) ❑ Diff Srr Co,iWnn=t Plcat(A)iind Ctrva(s) <br /> •If the facility Ctln uins tnorv.,lank%or disPensen,copy this form. Include intortaration for evi'y tank and dispenn;r ry the to iYity. <br /> C. Ctrflfecation-I certify that tht eytuprn nt Identified in this docsiment wuri inmpi 'rtedherviccd in amordance with the rnanufhtturcrr;' <br /> Qulrilalirrx:. Attached to chi, Ce"Jificmtion in information (c.g, uaetrttdicturr-"n' ch, L119 y) necessary to verily that this information in <br /> correct and a Plot Plan showing the layout of monitoring"atlpment. I+or any url ,aoteat eapnble of Zet+crating such reports,I have also <br /> sttacbattd tt copy of the report:(clutrk all tXw apply): U System set-up oU;%rm history report <br /> T ccimician Name(prisfj: ��,� //'{�&0_ Sigmalin [- <br /> Certification No.: ����-J—..`_ --_. License. <br /> M onitoring System CertifiGatinn <br />