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Site Address: �;' ,l n►ag. iso.: L" �� r L) City: Zip: 46 e) _ Facility Contact Person: kv, Contact Phone No.: () --?3 3-0 -"19 6® Make/Model of Monitoring System: 2r Date of Testing/Servicing: `/ L44 B. Inventory of Equipment Tested/Certified Check the a ro date boxes to indicate 2eciric equipment insected/servicei Tank ID: t 5 q F0 Model: _ 0 In -Tank Gauging Probe. Model: L Annular Space or Vault Sensor. _ __ Model: - s-� Piping Sump / Trench Sensor(s). Model: etc w,) - . p Fill Sump Sensor(s). Model: , o¢ ❑,,¢ Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: I Model: TZ crO ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment type and model in Section E on Pa a 2). Tank ID: fiC ❑ Tank Overfill / High -Level Sensor. 0In-Tank Gauging Probe. Model: 4// ,Q Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s)€ " Model: Fill Sump Sensor(s). I Model: ❑ Mechanical Line Leak Detector. Model: ,0'Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment pe and model in Section E on Paee 21 Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: E3 Dispenser Containment Sensor(s) ❑ Shear Valve(s). and Model: Model: � no— Model: FzO .. Tank ID: t U ,EfIn-Tank Gauging Probe. Model: c 0 Annular Space or Vault Sensor. Model: 7 Piping Sump / Trench Sensor(s). Model: w ~- Fill Sump Sensor(s). Model: �- ❑ �Vlechanical Line Leak Detector. Model: ,..T Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tnk ID: In -Tank Gauging Probe. Annular Space or Vault Sensor. Model: e"I /� ,f' " Piping Sump / Trench Sensor(s). ` Madel: Model: W FillSump Sensor(s). Model: ^- ❑ Mechanical Line Leak Detector. Model: 2r Electronic Line Leak Detector. Model: tail f� ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: Model: o Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chains) *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Cerdfication is information (e g, manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of -monitoring equipment: For any equipment capable of generating such reports, I have also attached a' copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Iet yy� m Certification No.: l Monitoring System Certification Signature:CIL '%�� License. No.: C1 rj 11'-I 3 1 Cc # 52.49115 w Ll 1