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yd':di� ) � i� � 1 �t• _ f HEA /+ Vic r fjaxb�xr ii''I Fft`�a�icl- O3 7p.Y77N ; (*'I 1A'1*'R(,1?0r: IJVI, ��,G .dld�'n l�M ;t � :s'PM 12. 52 Post Ojjrice Bor 3(, Thornton, Oy. 95686 (209) 794-0102 Fit X 794-0112 General Informnlion lily Name: 1) S,S eAL> h f r,a Site Address: % 5"6- e I 4, docility C'ontncl i ersnn: DIP v? 6.11k I* *j2. ('rmtnr I ('hone• No Mnke/Model of Monilol ing System 11. Inventtory of hyuilrnu,nl '1'e ll•tl/l 'e•rlilit•dl (wreck the appropriate boxes to Indicate specific a ndnmenl InsneclrJ/sr1 rlceJ: Rldg. No.:_ zip: 96;7.0,16 Tank ID: t ip lZe7 'Tank 11►: u )- ❑ In -Tank Gmrging Probe. hf(Arl: M.+t- / _. —_[.-_ U ln-'Unitk Gouging l'rolle. Model: _ Al O Annular Space or Vault Sensor. Modrl: 4 ®- QO k U Arnorine Space or V1ndt Srnsnr. Model: -AV0 _ U Piping Sump / Trench Sensor(s). Mntlrl: '70f A'62 L02 0 U Piping Sump / Tiroch Sensor(s). Model: 41 U'- �0 ❑ rill Strrr111 Seosot(s). Wilf•l' U fill 51111111 Se11Fo1(n). M1NIrl: U Mechanicnl Line I,enk 1 lrtrelor. Modr--1: U Mrchnnicul Line I enk DrIerlor. Model:- ❑ Electronic Line Leak Detector. Model: U Flectronle Line Leak Detector. Model: O Tank Overfill / Ifigh-Level Sensor. Model:. U 'Tank Overfill /I ligh-Level Sensor. Model: O Other (specify ui ment type and model in Section G cot Page 2). U Other (specify ui rnent type and rnodel in Section E on Page 2). Tank Uh 'Tank ID: O In -Tank Gauging Probe. Model: _ U In -'tank Gnoging Probe. Model: _ © Annular Space or Vault Sensor. Model. U Annnlnr Space or Vault Sensor. Model: O Piping Sump / Trench Sen.1or(s). Model: _ __- U Piping Srunp /Trench Sensor(s). Model: O Pill Sump Sensnr(s). Mfmlel:. U fill Sump Sensnrls). Model: Q Mechanical Line Lenk Detector. Model: U Mechanical Line Lenk Detector. Model: O Electronic Line Leak Detector. model: _ U P.Iectronic Line Lrnk Detector. Model: O Tank Overfill / Itigh-Level Sensor. Model• U Tnok (/vrrfill /I ligh-Level Sensor. Model: U Other (specify ui sent type and model in Section G un Page 2). U Other (specify ed ui rrrenl type and rrrodel in Section E on Page 2). Dispenser 111: '01P5 P / Dlxprrner 111: 1'e U 1, U Dispensrr Containment Sensot(s). Model: _?yl`t3f - 0 U Ilisprnser Coolnimornl Sensor(s). Madel: ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chnin(s). U Dispenser Containment nloat(s) and Chains . Ulapenser ID: -------... Dispenser 11): U Dispenser Containment Sensor(s). Model: ._ _ _ . U Dispenser Containment Seosor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). U Dispenser Containment float(s) and (_liain(s). U Dispenser Containment Moats and Chain(s). Dispenser ID: _ _ . _ - .. I llspenser ID: . ❑ Dispenser Containment Sensor(s). Madel: , _ U Dispenser Contninment Sensor(s). Mcxlel: ❑ Shear Valve(s). U Shear Valve(s). E3Dispenser Containment floats and Chain(s). I U Dispenser Containment Floats and Chaln s . n the facility contains move tanks or dispensers, copy this form. Irlrludr inforrnntion for every Innk and dispenser at the facility, C. Cerflnention • 1 certify that the erpdpnrrne ldrnli ird hr 1111.1 docnnwill was InvperlrrUservicetl In accordance with the manufacturers' guidelines. Attached to this Certification Is Infornrnllon (e.g. manufacturers' checklists) necessary to verify that this Infe m chid Irl correet and a Plot Plan showing the layout of rnonihrrhip equipment. For any equlpnxnt capable of generating such reports, I have also attached a copy of the re rt; rheck oll rh r nppirl. U Spalem rel -up U rr Malls- report C....• _ Technician Nnnrr (print): Ye C7 r m �s� Signnlmc: � Cerliffi-a ioo No.: 16& a-dbU! Hret se No.- 1'ngr 1 1/1*3 03/01 MonllnrhrR Sytlrm (:erltficnlfon