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Site Address: o y � City: Facility Contact Person: LX ''0 ,"? i V Contact Phone No.:(_) Make/Model of Monitoring System: Uy s-� iii �i -� n �, ; _ / 7 « Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sneciftr Tank ID: � L' t) it � Y?_ 'i'~ 4* 3, :„; ❑ In -Tank Gauging Probe. Model: CYanular Space or Vault Sensor. Model: W- Piping Sump / Trench Sensor(s). Model: 2 1 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 2)_ Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specifv eauinment tvne and Model: Model: Model: Model: Model: Model: Model: model in 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: Eon Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include Tank ID: — C > tr( j � ❑ In -Tank Gauging Probe. ©-A[15ular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (snecifv ecminmPnt tAm —A Model: Model: �_ )q h S Model: Model: Model: Model: Model: iodel in Section E on Paee 2). Model: Model: Model: Model: Model: Model: Model: model in Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). U Dispenser Containment Float(s) and Model: Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains) Formation 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 Certification 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 histery report Eon L.. Technician Name (print): `� '� jJ Certification No.: ='" D - Monitoring System Certification Signatut License No.: Page 1 of 3 03/01