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Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> TanklD: TanklD: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment t pe and model in Section E on Page 2). ❑ Other(specify equipment ty a and model in Section E on Page 2). <br /> TanklD: TanklD: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Others eci e ui ment type and model in Section E on Page 2) ❑ Other�sEecify e ui ment type and model in Section Eon Pa e 2). <br /> Dispenser ID: 13/14 Dispenser ID: 15/16 <br /> X Dispenser Containment Sensor(s). Model: VR-208 X Dispenser Containment Sensor(s). Model:_VR-208 <br /> X Shear Valve(s). VR-304 X Shear Valve(s). VR-304 <br /> ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). <br /> Dispenser ID: VENT BOX Dispenser ID: <br /> X Dispenser Containment Sensor(s). Model: VR-208 ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). VR-304 ❑ Shear Valve(s). <br /> ❑ <br /> Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chains ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> 2 2/21/07 <br />