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Site Address: 65-5 hj L.4, i S 7 City: Zi 95"20 , P� Facility Contact Person: -b N tS Contact Phone No.: (-110'1 ) .7q&- 0 �5 o Z. Make/Model of Monitoring System: -VEE b&AL e00 -e 'I U5 dao C Date of Testing/Servicing: ! / Z5/657 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Ta ID: b -7 ® c,-7 Ta ID: I S jn-Tank Gauging Probe. Model: M P- Fit 1ala nular Space or Vault Sensor. Model: % L/ 380 I Tank Gauging Probe. Model:tLVI k nular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: iping Sump / Trench Sensor(s). Model: Zoe ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: El Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Page 2). ❑ Other (specify equipment a and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging rob . Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space pac or Vault Sensor. Model: ❑ Piping Su / Trench S nsor(s). Model: g ❑ ;Fill SumSensor(s). Model: Mech ical Line Leak tector. Mo ❑ Annular Spa a Sensor. Model: Piping S p / Trench S sor(s). Model: Fill S p Sensor(s).Model❑ hanical Line Leak De tor. Model ❑ onic Line Leak De ctor. odel: 'Electronic Line Leak Deteciupo�odel: ❑ Tank Overfill / High -Level ensor. Model: . ❑ Tank Overfill / High -Level ❑ Other (specify equipment a and model in Section E on Pae 2). ❑ Other (s eci a ui ment =6 and model in Section E on Pae 2). Dis user ID: S 'Z D' user ID: 1 S k-.- ShSpenser Containment Sensor(s). Model' %� �spenser Valve(s). Containment Sensor(s). Model: ear U Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor s). Model: ElDispenser Containment Sensor(s). Model- ❑ Spear Valve(s). �� \ ❑Dispenser Dis Containment Float(s) p Shear Valve(s). enser nd Chain(s). © Dis enser Containment Float(s) and Chain(s). Dispienser ID� Dispenser ID: ❑ Dis of Containment Sensor(s Model- © Dispenser Cpntamment Sensor(s):, Mod ❑ Shear Valve(s). LJ Shear Va e(s). - ❑Dis enser Containment Float(s) and Chain(s). a__ _ iTr I r_•r- ❑ ser Containment Float(s) and Chain(s). .. We iacuuy cuucauis more imms or dispensers, copy this toren 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 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 a went capable of generating such reports, I have also attached a copy of the report; (check all that apply):System set-up B,41arm histery report Technician Name (print): its t`' Y - ( ` Signature:..--- J_i Y� -, Certification No.: _ �� License. No.: Monitoring System Certification