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Site Address: ✓�S__W, e ��,-� �� .. Facility Contnct Person: ._ 474- Make/Model of Monitoring System: _ (fir. 'Pvfi�v a!JC' T00(5 D. Invesntory of I;gllipssleitt 'Tested/('er•tii,ietl t5raek neereerlde bees to Indlenle snedtle euutmnent Insnected/servireds Cily: Sof "kms b -t-- zip:2�= f'nntnct Phan Nr,.: ( •X10 is &C.) I talc of 'I .alio};/Servicing: .�q_._li�--1 D� Tatak ID: V 1 0 0,0/ -. - . _ _ 'yank ID; l U in-Tnnk Osuging Pmbe. Model: O In -Tank Gauging Probe. Mralel:. O Annular Space or Vault Sensor. Mr,tIeI: O7 a9(' - _�_ U Annular Space or Vault Sensor. Model: C'9 ,44 "b ,407 -NB O Piping Sump / Trench Sensor(#). Mmlel: 7 9 y 31%70 - a D _ U Piping Sarnp / Trench Sensnr(s). Model: O Fill Sump Sensrrr(s). MfOrl: U Pill Storni Sensnr(s). Model: U Mechanical Line I eak i reteclor. Model: U Mechanical I .hue I &nk Deteclor. Madel: _ U Electronic Une Leak Detector. Mrnlel: __ - _ U Plectroule Line Leak Detector. Madel: O Tank Overfill / High-level Sensor. Model: U Tank Overfill / Iligh-Level Sensor. Model: O Otho (vocify equipment type and model in Section E on Pae 2). U Other (specify equipment type and model in Section B on Pam 2). Tank ID: Tank ID: O In -Tank Gauging Probe. ModV U in=rank Gauging Probe. Model. O Annular Space or Vault Sensor. Mod U Annular Space or Vault Sensor. Model:O Piping Sump / Trench Sensor(s). MrKlU Piping Sump / 'french Sensor(#). Model•O Fill Sump Sensor(s). M(AU Fill Sump Sensor(#). Model: O Mechanical Une Leak Detector. MIXlU Mechanical Une t eak Detector. Model: O Electronic Une leak Detector. MrlU P.lectronic Line leak Detector. Model: O Tank Overfill / Nigh -level Sensor. Model: _ _ _ _- _ _ _ U 'rank Overfill / Nigh -level Sensor. Madel: O Other Well equipment type and model in Section E on Page 2). U Other (qwify equipment type and mudd is Section It an Poilis 2). DMpmwID: oOI40�-__-_ Dispenser O Dispenser Containment Sensot(s). MndeL 794 b 0 "� U Di#Penser Cialtaluaenl ,4rn#m(#). Model: U Shear Valve(e). U Shear Velvets). O Diepeam Containment Floats and (-'lain(#). U Dispenser Containment Moat(s) and Citatn s . Dispenser ID: _ ------ Disperaler ID: O Dispenser Containment Sensor(s). Model U Dispenser Containment Sensor(s). Model: O Shear Valve(s). U Shear Valve(s). O Dispeow Containment Float(s) and Chain(s). U Disperim Containment Floats and Chain(s). Dispenser ID: _ _ . _ . _- _ Dispenser ID: O Dispenser Containment Sensor(s). Model U Dispenser Containment Sensor(s). Motel: O Shear Valve(s). U Shear Valve(#). Whisenser Containment Floats and Chain(s). U Dispenser Containment Flost s and Chain(s). off the facility contains more tanks or dispensers, copy this for in. include information for every tank and dispenser M the facility. C. Certification - I certify that the equipment Identlned in the document was InspecterVservlced In accordance with tide r2 — -9 guldellnes. Attached to this Certification I# infornmilon (e.g. manufacturers' checklists) necessary to va* that Nis MafMllio r correct and a Plot Plan showing the layout of monitrrring egerlpnenl. For any equipment capable of generating tach reps- l iitara 4* attached a copy of the report; (c eck.all that apply): U System set -lop to r if y report Technician Name (print). ,�I11_f» fir/ -b.-. - . signntmre:.._ >.� Certification No.:_(p.liA�C:+Gv d I.irrnsr Nn. Testing Company Name: 04 fj�o rdLA - T `r' St Thune• Nn. ( Cl _-)>9-1 ` AY D V rage i of t 031111 Mordtordng System Certification