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r <br /> :TF71MA003 <br /> i -E <br /> �ltrA7,77'l'TF.•WIA OF f rNI)FRt�ROUNI) 7ANKS117'A7- F.7, <br /> R <br /> ENVIRHEALTH <br /> Post Qjflce Bon 36 Thornro�l, W. 95686 (209) 794- 1��R112 <br /> General Inft)rml►tion <br /> Facility Name: (�C+ ate f11dR. No.:_ <br /> Site Address:--- $ : c ,z F- I t'ity: . '`r 6'1 Zilr <br /> Facility Contact Person: ITQ FP 0nnlnr•1 I'hnnr No.: ( 209' ) 4179- <br /> Mnkr/Mo<Iel of Monitrrtink Svstrnr v-R ��—` �� I h0v oil '1'rslin)�/Srtvirinl!: /�/� <br /> 11. Inventory of H;qulpnu'nl '1'e•sle'ef/1 'e•rlilird . <br /> Qteck the appropriate boxes to Indicate s ecltic equipment las rested/srt vlred: <br /> Tank ID: L }' i 'Tank 11): _ _77. <br /> ❑ In-Tank(mulling Pmhr. Madel: U III-Tri nk OnuRinR 1'tobr. Model: <br /> O Annular Space or Vault Sensor. tvindrl: 4 52� U Annulm Spm•e ar Vnnit Sanson. Model:+_7-57_,, <br /> U Piping Sump/Trench Sensor(s). Model! 1 Lqk 1�rg7 -"2 DR:� U Piping Sump I Trench Sensor($). Model: 7 '``• PO <br /> tF­ <br /> U Fill Surnp Sensor($). Madel U (rill Sungr Sensrrr(s). Madel:_ ., _ <br /> U Mechanical Line I ink 1 nrlertrrr. Madel: U Mrchnnicn)Line 1 ink Drtcrtor. Model. <br /> ❑ Electronic Line Leak Detector. Model: U Eircnonle Line Leak Detector. Model: <br /> O Tank Overfill/lligh-Level Sensor. Model- U 'frock Overfill/I ligh-Level Sensor. Model: <br /> ❑ Other(specify equipment t and model in Section E un I'n e 2). U Other(specify equipment t and model in Section E on Page 2). <br /> O In-Tank Ganging Probe. Model:• U In-•fnnk(ranging Probe. Model:_ <br /> ❑ Annular Space or Vault Sensor. Model.- 7,is/�Fr(� —H� U Annular Space or Vault Sensor. Model. <br /> O Piping Sump I Trench Sensor(s). Model_7 a•`G�U—-,X-O U Piping Sump/Trench Sensor($). Model. <br /> U Fill Sump Sensnr(s). Model:• U fill Sump Sevrsor(s). Model:_ <br /> ❑ Mechanical Line Leak Detector. Modri. U Mechanical Line Irak Detector. M►Xlel. <br /> ❑ Electronic Line Leak Detector. Model: U Flectronic Line Leak Detector. Model: <br /> 0 Tank•Overfil)/lligh-Level Sensor. Model: U Tnuk Overfill/Iligh-1 revel Sensor. Model: <br /> U Other(specify ui ment type and model in Section li on Pae 2). U Other(specify equipment anent t and mmolel in Section E on Paste 2). <br /> Dlspemer 11►: 1)Isprmer ID: <br /> U D1xLw` srr Containnvrnt Srmoits). Mnrirl' U Di$lenset t'rminin►nrnl Sensru(s). Mattel: <br /> O Shear Valve(s). U Shear Valve($). <br /> U Dispenser Containment Iluat(s)and Chnin(s). U Dispenser Containment Floats and Chain (s). o , <br /> Dispenser ID: _ Dispenser 11):_ <br /> O Dispenser Containment Sensor($). Modrl: _..�___ .._.. ._.. _ U Dispenser Containment Sensor(s). Model: <br /> O Shear Valve(s). U Shear Valve($). <br /> ❑ Dispenser Containment Float(s)and(-ltain(s). '` ' ` U Dispenser Containment Iluat s and Chain(s). <br /> Dispenser I D: __,__.. . _ Dispenser ID: ' <br /> ❑ Dispenser Containtrent Sen$or(s). Model:__.__._.._.... .. _ _ U Dispenser Containment Sen$nr(s). Model. <br /> ❑ Shear Valve(s). U Shear Valve($). <br /> ❑Dis nser Containment Floats and Chain (s). ` ' U Dispenser Containment Float(s) and Chain a. <br /> *if live facility contains mese tanks nr di%pen$ets.copy this foil". Include information for every tank and dispenser at the facility, <br /> C. Certifientioll -1 certify that the rgndpnent ldrullned ht tills document was hnsperh4l/serviced In arcordance with the menufacturen' <br /> guidelines. Attached to this Certification is Information (e.g. manmfachrrers' rhecklists) necessary to verify that tills Information Is <br /> correct and a Plot Plan showing the layout of mnnftnrlog equipment. For any egnlpnnent rnpaMe or generating;such reports,I have also <br /> attached a copy of tire report;(rherii all shirt apply): U System set-lilt U 6jor u ilia ea►ort <br /> f echnicino Name(print): Si)!nnhne: <br /> 'ertif►ralion No.; �`/,ba�L3(���r"` I.ire nsr No.: e?,> <br /> 1'nRr I orf 1 03✓01 <br /> .1olviloring System Cerlifirnfion <br />