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f forrr <br /> OCT 16 <br /> 20 <br /> 02 <br /> 'VfA1.171 �rx'71N(7 1;-f N11PR ;ROfNl► 7ANK.f A7'AITY)NnVII RATEV <br /> 7 <br /> EWRONMET HEA <br /> LTI , <br /> Post Office Box 36 7horrnton, Or. V5686 (209) 794-01 NJ%WJUi�0112 <br /> General Infornnni ifrll <br /> Facility Name: jp re/C i 9 ( f�r t wa� ��-y,✓i t'� --_ _ IIIdR. No.:-- <br /> Cite A(I(Iress: _ N '•E�'►' t'it).. K0 e / <br /> f 7111;_ <br /> Facility c oninct Terson Dcd __---„— _ Cmilncl ('hnrtr Nit., (_) <br /> Make/Model of MonitrrrinK Sysa nr �a -_ 1 rnlr•nl Irslinf!/,Srrvicin)! <br /> 11. Irrvenitrt-y trf Ir;glollrurenl '1't•tlt'd/t 't r pili,O <br /> Umk the oppropirloole boxer to Indicate spec tic t ul nrrerd Ins,read/ren aced: <br /> Tank III: ,Q1194 'Tank 11►: _ <br /> U Jn-Tank onaitinl:Prohr. ” Mnrlrlt U In l'nuk(inuRinR I'rohr. — Model:•------._-- <br /> UnradarSpacenr Vnuh Sensrn. Mrulrl f j/ �pPWGQr- U AmmInt Since(rr Vnult Srnsrn. Mrxlek <br /> l7 Piping Sump/'KreacJLStuaty(e). Modrl "� "/ U Piping Sump/'french Sensor(s1. model: <br /> u Pill So►rpr SeviRmov). Mrrrlrl U fill Sump Sana,,((+1• Mmtel_- <br /> U Mechanical Line I enk Drrrr•rrn. Mrrrlrl' U Mrchnnicnl Line I,rok Drtrclm. Mnrlel:_ — - <br /> U Plectronic Line Leak Oetretor. Mrrrlrl U Iilrctrordc Line Leak Detector. Mrxlel: <br /> U Tank Overfill/Iligh-Level Setlitrr. Mrrrlrl•, U 'Tank Overfill/high-Levet Sensor. Model- <br /> E) Other(specily equipment type and mudel in Section E on I'n e 2). U Others xif equipment type and model in Section E oh Pe 2. <br /> Tank ID: Tank ID:_ <br /> ❑ In-Tank Gauging Probe. Modrlt U In-'f"Ilk(moging Probe. Model- <br /> El Annular Space or Vault Sensor. M(Idel: U /lmminr Space rrr Vault Sensor. Model. <br /> U Piping Sump/Trench Senerrrlel. Model: U Piping;Sump/Trench Serrsor(s). Model- <br /> U fill Slimp Sensor(s). Atrxlel.• U Pill Sump Srnsrrrle). Motlel. _ <br /> ❑ Mechanical Line L,enk Detector. MurlrL U Mrclinnirnl Liar leak hNectrn. M(xlelr <br /> El Electronic Line Leak Detector. Mrxlel• — U Pledronic Line I.rnk Detector. Model- <br /> EJ Tank Overfill/high-Level Sensor. Mnrlel: U '1'mrk Overfill/IliRh-1 evel Sensor. M(xlel:_ <br /> U Other(specify ui neat 1 and nt(xlel in Section Lr on Plop 2). U Others(specify equipollent l and trxxlel in Section E on Page 2). <br /> Dispenser ill: H e. M/p. j04 ij 1114penser ID: <br /> U Dispenser Containment Srniot(s). h rrrlel' U Dislrensel Vontaiomlrnt Serrsm(s). Mrxlel:_- <br /> U Shear Valve(s). — U Slim Valve(s). <br /> O Di neer Containment floats slid Chnim(s)• U Pis censer Containment Floats and Chain(s). <br /> Dispenser 111:- <br /> U Dispenser Containment Sensor(s). Model: _ U Dispenser Containment Sensol(s). Model: <br /> O Shear Valve(s). - U Shear Valve(s). <br /> O Dispenser Containment dost a and C hain(s)• U Vis user Containment fluat s and Chain a. <br /> Diaper w ID: _ ' 1►Ispenser III: <br /> ❑ Dispenser Containment Sensor(s). Model --. U Dispenser Containment Sensor(s). Model: <br /> U Shear Valve(s). U Shear Valve(s). <br /> UDis neer Ctmlaitunent neat s and Chains. U Vis neer Containment(foals and Chain(s), <br /> .If lire ftrcilily contains crane tanks or dispensers,copy tlrie Irrrm hrr•Imdr irdororntion fnr every lank and olispenaer at ilia facility. <br /> C. CerUflenlioll -1 certify ilia,the egnipnrerrl I(Irnllllyd In rale d(x•onrenl was IrepecterUservlced In accordance with the n amdaeturerrs' <br /> guidelines. Attached to this Certification M Information (e.g. tnnnmfactnrertt' cherklisls) nece+aary to verlfr that thb Intonandotl b <br /> correct and a Plot Plan showing the laynml of mnollor inR rrinlpmenl. For any equipment capable of generaling Inch reports,l hate mbo <br /> attached a copy of the report; rhrrA off Jnr oppirl: U 14►•slrm set-loll U an clap rrr a►t►rt <br /> Technician Name(prhll): �y T R3 . t.�0 Si�nnnnr �r ;i� <br /> Certification No.: I irrn�r No.• <br /> 1'nRr t of.t O.VOt <br /> 111onilorhrR Syslen►Cerlificnfhrnt <br />