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Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System /1/1/p Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate gecific a ui ment inspected/serviced. % Ta5rrl�l k Gauging Probe. Model: �"%%*� 7+ / Tank ID: Q'1"n-Tank Gauging Probe. Model: ar Space or Vault Sensor. Model: 2` N i� ular Space or Vault Sensor. Model: v l�l'Piping Sump /Trench Sensor(s). Model: T4WL73 c . S ❑-Piping Sump / Trench Sensor(s). Model: ; ❑ FjU-Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ,! P OrMechanical Line Leak Detector. Model: / 77,P G` ews ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill /High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ther (s e i ui ment a and model in Section E on P e 2). ❑ Other (s a ui ment a and model in Section E on Pae 2). ilkID: Tank ID. rTainEl -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model:nnular Space or Vault Sensor. Model:❑Annular Space or Vault Sensor. Model: ping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FillSump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑Tank Overfill /High -Level Sensor. Model: Other (speEffj equipment a and model in Section E on Pae 2). ❑ Other (s eci equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: a •� 1❑ ❑ Dispenser Containment Sensor(s). Model: 6 7 ❑ Dispenser Containment Sensor(s). Model: } - ❑ Shear Valve(s). ❑ Shear Valve(s). _2 Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID- Dispenser IID:. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID• ❑ Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: E3 Shear Valve(s). 13 SbearValve(s). ❑Dis enser Containment Float(s) and Chain(s). 9_RLspenser Containment Float(s) and Chain(s). "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'Periification is information (e g. manufacturers' checklists) necessary to verify that this information is -correct and a Plot Plan showing the layouf ofmonitoring equipment: For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Cl System set-up ❑ Alarm history report Technician Name (print): Ll P 1 yetM m C) Signature: P Certification No.: ig6 P License, No.: C19 _ lit 3 CC 52.L49 \ 15 - LC i Monitoring System Certification