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1171171111 <br />Bldg. No.: <br />Site Address: ! Cf ° c �G''�# t, All OL 11 . J _ City: U D - oaf,. S <br />Facility Contact Person: %O�J.Contact Phone No.- ( ©?) 37 �1 - 0 a, tip <br />Makc/Modcl of Monitoring System: V e,,Ae tr - FDo °l- )rG�j ` t i'3 Date of Testing/Servicing: Y P ° 05— <br />p.2 <br />B. Inventory of Equipment Tested/Cerffind <br />tai -k tbe;-Pompriate how to indirste <br />Wamc aprilugaent inspeawwwnim <br />n -Tank Gauging Probe. <br />Z <br />Model: era P r P <br />Annular Space ar Vault Sensor. <br />Mo del: ' <br />XPiping Sump I Trench Scnscrr(s). <br />Modeh y <br />O <br />'Fill Sump Saasor(s). <br />Model: 7F�1 ?XU - <br />2D8 <br />R IVechanical Une Wk Detector. <br />WA -1: <br />.VwMcctronic Line Leak Datcaor. <br />MCX14: L R <br />U Tank Overfill / Nigh -Level Sensor. <br />Model: <br />® Other ( ui meet t3W and model in Section E on Pa <br />2). <br />Xl[T; <br />-Tank C,sugittg E'raba <br />Model: <br />Annular Space or Vault Sensor. <br />Model.- <br />. <br />Cr Piping Sump / Trench Sensor(x), <br />Madel: 7,9 <br />2CFill Sump Sensor(s). <br />>ftchanical Line Leak C)eteetor. Model: <br />lei" Electronic line Leak Detector. Model: PU r)_ <br />0 Tank Overfill / High -Level Sensor. Model: _. <br />Cl Other (specify equipment type and orodel in Section E on Pave 21 <br />ID: 1 'C' -z- <br />Cl <br />U Dispenser Containment Sensor(s). M(xYCt: <br />❑ Shear Valve(s). <br />U Disnanxer C'ontminmenr Rcu tha) :end rhninti <br />In -Tank Gauging Probe! <br />'*Annular Space or Vault Sensor. <br />.d Piping Sump / Trench Sensor(s). <br />,WFiI Sunv Scas"(s). <br />D iced Line Leak Dabcctor. <br />catrunie line Leak Detoctor. <br />U Tank Overfill / High -I evcl Saes. <br />G Oche' cQuimmot Ivr= and <br />Tank Gauging Proabe, <br />Annular Space at Vault Sensor. <br />Ylliping Sump I Trench Scnsor(s). <br />X"Fill Stump Sere:uu(s). <br />U Medmical Line Leak Detector. <br />eetraide tine Leak <br />D Tank Oveaiill / -Levet Sensor. <br />❑ Other (specify ettuite =t tyDe and , <br />47-1-M s. 1T - <br />Model: fiAOa C -f P <br />Model: 79!PXFa - XOF <br />Model: _ <br />Model. <br />Model• <br />cooler in Sec:'ticm R on Paac 2). <br />Dispezow I)D: tf 1-f <br />U Dispenser C'.cmtainn=d Sensor(x). Model: <br />U Shear Valve(s). <br />Dee ID: Dbpmw W.. i <br />U Disponscr Containtount Senwr(s). Model: % r D Dispenser Cont tinnxnt Sensor(s). MrAa. __79, <br />LI Shear Valve(x). Cl S'tremr valvc(s). <br />U Dispenser ser Containment Floats) and Chnin(s). D Die sea Containtnent Floats and Chaiv(s). <br />U Dispenser Containment Sensor(s). Model: 7 �! 79LV-L-O� U Dioses Containment Sensor(s). Model: <br />(3 Shear Vulve(s). U Shear V'd*'-')_ <br />2R) eraser Cooueinruntt 140at(s) and (main s). U Njo= Containtnent Flow(s) and Chain(s). <br />wYf the facility t ontairtc more tanks or dispcttsers. copy this fcstn Include <br />informnation for every tank and diopex = at the facility. <br />-z0e <br />C. Certification . I certay that the eqtdpment idebtWed in this domunent was fns serviced in with the mnufactura rs° <br />guideiiam Attached to this Catficadon is info tion (c g. manuflwhirar cheeldists) amessary to ve fy that tlrir, ' nation is <br />correct rand a Plot Ilan allowing the luyoui of aponittorit►(; eq For any equipment capable of generating such r rta, I have also <br />atLvbed a copy of the report; (check alt dw apply): yotto're set-up ALnn histery report <br />Technic:isn Name (print): �GVIJKPU-- _ SigAOtttutr, _(�--. <br />Certification No, -- License <br />Monitoring System Certilricatioto <br />