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low WOW <br /> [5,IE7 lu <br /> Af forba-Te. <br /> JAN 13 2003 <br /> 'V(1A1,17T 7FS71Nf;OP'I 1AII)FRGROUIVI) 7AAfK.%!A 7'A 1T01?0Afl1,Ej?A7-E.V' <br /> ENVIRONMENT HEALTH <br /> 7 <br /> 2 <br /> VUA) <br /> 0 <br /> 0 <br /> 3 <br /> T �EA�TH <br /> fri <br /> Post Ojflce Box .16 7'horrmyn, 95686 (20V) 7V4-#WT1AWW4-0112 <br /> rnl IjjrrjjnjIf)jj <br /> Generni hiforivinjimi <br /> Facility Name: CLO V_ Illdg. No.:- <br /> k) <br /> Zill: <br /> Facility Onifnef Persmi: Cmiliff-I I'limir No.- <br /> Mooke/hImlel of Kfimilminp <br /> It. Ifivelifory of Irollillmil-olf <br /> (beck the apprepslate boxes to Indicates eclfic egollanent Inslit(left/ser fired: <br /> Uln-Tank((ringing flinfir. Itififir" !Ej Uln Tank("Iftliging Vitifir, model: 61 <br /> (3AnnularSpace of Vritill Sensm. Fiflidel: . Lf-Atintilm Space tit Viunli Sril.-mr. Model: 7-C, .6-r�, <br /> d'Piping Sump/'('tench Semmoo. Motirl- - 7"5,4P— 14 W-PipingStionji t T,encit senstil(g). Model: U1115 <br /> LJ_f U Fill <br /> Suorp Senmit(ti). <br /> L-1-Mechanical Vine le."k I)riecim, Model _-Ger-,00/-*//-47 W'-K-Irt-hindejil I.1ne lenk Driecitit. Model: 1 <br /> E3 F-Ifectr <br /> Tank <br /> Line Leak Delecitir. hImIrl: U Plectionic Line Leak Delecifir. Mollel: <br /> CJ Tank Oveirill/high-Level Senear. MiArl:. U Tank Overfill I high-bevel Senimr. Model- <br /> 0 Other(specify equipment type and inudel in Section E on Vage 2). U Other(speciry equipment type and onodel In Sectio e2ji. <br /> Tank ID.- _p *['milk If)- <br /> alln-Tank Gauging Probe. U In-1ank Clanging I'mlie. Model- <br /> 13'Annulsr Space or Vault Sen-mr. mimlet., U Arimiltif Space fir Vault Sensor. Model: <br /> Whiving Sump I Trench Sen-mr(R). MOO!, Af.LG U Piping Suffill ITlench sellmit(m). Mtxlel: <br /> O no snorip sensor(s). Kil"lel:� , U Fill sinnil Selml(g). WOO: <br /> Id Mechanical Line Leak Detector. Model �tP IW—/-/7 U Mrch"nictil Line Leak Detector. Mqxlel: <br /> U Elecimnic Line Leak Defector. model: U Plectronic Line Leak Detector. Model: <br /> U Tank Overfill I high-Level Senwit. Model- U A rink Ovrifill/Iligh-I P.vel Selirtnt. Model: <br /> IU Other(specify equipment type and model in Section E.on Page 2). U ullief(specify equipment type and model In Section E on Pme 2). <br /> Dispenser ID: Dispenser ID: <br /> U Dispenser Containment SmimmiR). h1tidel, 5-rdo VU U Dimpenitel oilvininnirlit Srilmill(s). Moolel: S,_r753_U5 <br /> EJ Sherr Valve(s). U Sliest Valve(s). <br /> U Dispenser Containment nualCs)and Chain(s). U Disirenser Containment floats and Chain(s). <br /> Nxivemr 11111- a:I- b ____ __ _. -- Dispenser ID:_ -7 tle <br /> UDIgMnserContnininentSenitur(q). Nindel:_'577 Ui)iqpe"itetCoitiniiiiiientScliltol(s). Model: 51-P MA-5 <br /> 0 Shear Valve(s). U Shear Valve(s). <br /> _U Dispenser Containment float s)and Clinin(s). U DispensuCon(ainnomit floats)and Clisin(s). <br /> Disperoser ID <br /> U DispenlieFContaininent Sensor(s). Madel-... U Dispenser Coninininent Sensor(s). Model: <br /> U Shear Volve(s). U Shear Valve(s), <br /> EJDismnser Contaimnent Moats)and chaill(s), U Dispenser Containment Floats)and Chaln(s). <br /> Wilie facility contains imite tanks of dimpemeog.citify Illit: form in(.111tip information for every tank anddittrienvier at the facility, <br /> C. Cerflnenflon -I certify that the rillill"lle"t Illevillriell Ill 1111-1 410C11111will was Inspected/Rerviced lit Accordance with the niminuredurel <br /> guidelines. Attached to this Certification Is I"(forninflowi (e.g. ninvinfachirers' checklists) necessary to verify that thb latormdIm b <br /> correct and a Plot Plan showing five layout of ovio)lintinr etivilitniterof. For any ropolivintent capable of generaling such rvor*I INV*able <br /> attached a copy or five report;(chick all thal'arptir 1! USYrifellf met-till u lar tf,r_­re I <br /> Technician Native(pilow Z VI-e P rvi r) Y va <br /> CertifirslinnNo.: I if-f-1141. Na. <br /> Pngr 1 of 1 0.1/01 <br />