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P.IONITC)RiNG SYS I V%l I-ER'l IFIGAI-ION
<br />For Use. By All Jurisdirtiows Within the State of
<br />fy Ghaplui 6 7, H,..altii aooSafety Codd; Chapter 76, Divisicin 3 Tii.:,,,, :?J',
<br />a:ld ; ,I 'it
<br />If 1no.'il 111an o14!
<br />D^,J UO `01' ead I iXIL if Y I bj
<br />the wdinicitm Miu (,I
<br />j A JG,;
<br />f,lic ii, if Tfie rnubl siijbnrt a c.-q'y G1 '5 1z"l-n ,C, !h3
<br />agc.rcy rt_.gL,!at;nD US n cta�,
<br />Intor -nation
<br />�
<br />Na, -ie, [CON LUBf,l rutqf-
<br />City: STOCKT, ON
<br />zip =5'210
<br />_c- 1,i:I.J: esb UWD WEST' LANE
<br />Contact PhOnc NO: 4 73-4503
<br />r.3tt, of
<br />C,c)Wact Pers o: JMAN.AGER. .......
<br />. .... .....
<br />Yc�-Icd cl Mordoring Snystew. TANKGAURD
<br />Work 0"dcr Nlj!16fGT: 2222651
<br />11,xy cif Equipment Teste d/Certif ied
<br />Check the appirupic4,!�. tl,vt cid
<br />cale spe.I-;ifI,,,eqjiprof I ":Cte(J/S eivIced
<br />4 !'1), li-`iASTE OIL
<br />Taiik::D:
<br />F!oba Model
<br />or vault Slrlsclr klodei
<br />!.)I
<br />IQ St.;w;,/Trun(..h sensors) Kloclet
<br />Pi pi ng Sup 1 Se
<br />Fill SL.01,' S�nC,IS�
<br />i. in L(,ak D,,lector. M(Acl:
<br />J-_; ..ne Leak, Delxtor. Model.
<br />Electronic Line Li4,.N Ele
<br />21,t i 1_.Hji h Level Snnor Modd
<br />Tank So 11,.de I
<br />type and mode, in Section E on p000, 2).
<br />Other cspicify lypa-�j rod,_, w E_ oc,
<br />Tank ID:
<br />V-. .,_4 Probe looclei
<br />Pli
<br />v Vault S.nsi Model.
<br />Anriulqt Space or i I I 5e,t
<br />Fw
<br />D(?ectrir. MWC!
<br />J, no l.e,,,k Di Model
<br />Elenit,), iwI 1nf
<br />F fi 10 !i(jh-Level Sen',ol Model
<br />j Tank
<br />(sp,,I.Ay equymf�.(Il tyrx,, and fnoc�cl it) o E on page 2).
<br />5.
<br />cnsr:, Coritainv;t�.nl. Sr.,-,,,or(S i Mudet .. .....
<br />Disix. --c
<br />it
<br />Shdar
<br />eraser _cintainirio,.t 'Roa!(s) and Uiainksj
<br />r ID
<br />Dispenser ID.
<br />peni�e
<br />Sensor(j) Ivlodei:
<br />et
<br />Shear Val ve(3i
<br />'v
<br />_J
<br />C' Flcatffi and
<br />- ------ ------
<br />sl;1111�Cr ID-
<br />er U:
<br />Dispenser
<br />ent S
<br />vol
<br />She it
<br />,rt Floal(s) ;rGha n(I -
<br />r �j
<br />r,
<br />If thf, fadlity ii more tanks of disp��,nsersi, copy this form. 111C!Udf� iTlf-_,C!', '00'. 1 - I
<br />ity,
<br />d��oce with ire r,- 1wf2dUf(J Dl
<br />01"Irtify that the equipo .�,Aific(j in this do,,,umeril w, ac(;or
<br />Attached to Information (e g n-lanufiacturers' checklists) necessary to verify that this information is col rect.
<br />cind a Site Plan shovmqj t I�Iyout of monitoring equipment. For any equipment capable of generating Such reports, I h@,j,le also attached
<br />a copy of me (Check all thit apply): System set-up report; 11 I Alarm history report D
<br />NAME:KEITH W)WAN -- ---- __ SIGNA! URE
<br />)NE NO
<br />"'UMPA_NY-kr..L�09y
<br />
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