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Dr f foxbar Q %Lr J6 R 2 4 2003 (IAh (ln�,/7i 71.5'7/NfJO1 I�NI)rR(;RO(lNl) 7nNl�.Cn7'nl7rE�fIiII1it��FESALTH Post Office" ffice Box _ 6 Thornton, l a 95686 (209) 79��ZSE��,�794-0112 General Info/rmnlion FAcililyNAnle: t�✓'�- �'�j 5 ,, },.� flidF. No.:_ / Cite Addrrss: _-- / '/D W C Lr a r t-.P r W�� e( (•ily `� J %" 1 t �6 ! l� �! Zip: qSo�`d C� _ / Facility C•onlncl person: (�-r � I ('rminr•( 1'hnnr No.- ( 7 C�-? ) J?bb, _- '? A?7 Mnke/Model of Moniloring Syslrnr , �jca I c e?j {�1/(e-- 1)nlr rel '1'rslin)!/Srrvir iol! / V ----- 11. Ittventof-y fir ITdllrll)IIIelif '1•eMI-41/l 't•rfiliell check the appropriate bones to Indicate a eciftc equipment Ins meted/nee r•Ired: Tank ID: P 1�1 I, 'Tank 11): — - -'S 1. -._�---- ❑ In-Tank Gnieging Probe. Mndrl r5 U In Tmuk(imaging Probe. - Madel: Z O Annular Space or V0n11 Srnsor. Model: %" Q;r.:O1le,P4r) U Annulne Space or Vnuh Sensor. Model:' /D h 71�0�s ❑ Piping Sump/Trench Sensor(s) Model: 77 VV 00/ U Piping Sung,I'1•rench Sensor(s). Malel:r+'i- di >:c `/•w DE C Cl Fill Sump Sensor(s). N1101-1., arin U fill Sump Srnsrn(s►. ModrL• U Mechanical Vine I.rnk I)rtrctrn. Model U Nlrehnaicrd [.life 1 enk I)rlrc•Irrr. Madel: O P.lectronic Line leak Detector. Mr+drl: U Electronic bine Leak Deteclor. Model: U Tank Overfill/Ifigh-Level Sensor. Model: U 'link Overfill/I ligh-l-evel Sensor. Model: ❑ Other(specify ui ment type and model in Section E(pit Pn e 2). U Usher(specify ui ment type and model In Section E on Pago 2). Tank 11): --_-�- 'Tank II): _.._ ❑ In-Tank Gauging Praha. Model: _ U In-'Tank Cinaging Probe. Madel:_ O Annular Space or Vault Sensor. Model: U Annalnr Space or Vaull Sensor. Males: ❑ Piping Sump/Trench Sensnr(s). Model: U Piping Sump/ bench Sensor(s). Madel: U Fill Sunip Sensar(s). Model:. U Fill Sump Srnsor(s). Model:_ * ❑ Mechanical bine Lenk Deteclor. Modrl: U Mrchnnical Line I enk Detector. M(XIOI: ❑ Electronic Line Leak Detector. Model: U Firctmnic Line I.enk Defector. Model: ❑ Tank Overfill/Iligh-Level Sensor. Modr1: U 'Tmrk Overfill/Iligh-Leve) Sensor. Model: ❑ Other(specify ui inent type and model in Section 13 un Page 2). U Other(specify equipment type and model in Section E on Page 2). Dlrpenger fl): / �- �2_ Dispenser ID: 'S V e, U Dispenser Containment Srnmot(s). Mollri' irj :1 (Jt�V010 U Dislrrnser(•oofninntrnt Senmtn(m). Madel: LoD P U Shear Vnive(s). U Shear Valve(s). O Dispenser Containment float(s)and Chain(s). U Dispenser Containment floats and Clinin s . Dispenser 1D: ') �( Dispenser ID:_ ❑ Dispenser Contsintnent Sensor(s). Mrolel:QW4Q�,.06W/0 U Dispenser Containment Sensnr(s). ❑ Shear Valve(s). U Shear Vnlve(s). ❑ Dispenser Containment(loaf(s)and Chnin(s). U Dispenser Containment floats and Chain s . Dispenser ID: ___.__._... . - . Dispenser 111: - ❑ Dispenser Containment Sensor(s). Model-__-_.-- U Dispenser Cantninnrent Sensor(s). M(r(lel: ❑ Shear Valve(s). U Shear Valve(s). LIDispenser Conteirunent noal s and Chain (s). I U Dispenser Containment floats and Chain(s). off the facility contains trnne tanks or dispensers,copy this form Include infornmtion for every Innk and dispenser M the facility. C. Ce-rlificafloll -1 certify that live egnlpnent ldenflned hr this drrrnnwnt was Irivpeeled/servlcevl In accordance with the nonufacturers' guidelines. Attached to this Certification Is Inforn+nflnn (e.g. manufacturers' checklists) necessary to verify that Oda Information Is correct ands Plat Plan showing the Inyouf of mnnllovinR equipment. For any equipment capabie of generalinit such reports,I have also affached a copy of flip report;(cheek all thM_.nWO! U System sell-up U A rm,hinIory)report--_._ Technicimn Nnnre(print): CerlifcrIlion No.: L/ License• No.. 1'nQr I or:% 03/01 Moniforlop Sysfem Certification