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t p <br />Work Order: 2237782 <br />. �■ kt <br />In -A jAffvrba,-'(ff- <br />s <br />Post Offlee Box 36 Thornton,, + Jr 794-0102 FAX 794-014 <br />%cility Name: KIT, h I rot MX, ft '?C) Bldg. No.: <br />SiteAdilmas: _ J_ J:z--M P` Id't a) T7 r— City n4 i '+t Zip: Z?6r�'}`C�. <br />Facility Contact Person: 1#1 X+f Contact Phone No.: (204J ) 3 6 8—'-- Q <br />MskelModel of Monitoring System: rF Date of Testing/Servicing: �/ 5 J-�` <br />B. Inventory of Equipment Tested/Certified <br />d/Certified <br />Ems fadfeate re <br />Chedt tae 410=- cc to <br />Tank III. ! C" is .� <br />Tarsk M. L f h yt <br />O In -Tank Gauging Probe. Mudd: <br />❑ in -rank Gauging Probe. Madel: i ' � <br />• Annular Space or Vault Samar. Model: <br />Annular Spann ar Vault Sensor. Mod 56210"'Z-40 <br />O Piping Sump i Trouch Scasm%. Mudd <br />❑ Piping Samnp f Trewh Sonsor(s)- Model' <br />® H11 Surnp Scnk*gl Modd: <br />a Fill Sump Scnsmr(s)_ model - <br />E3 Meahsnical Line Lark Detector. Model: <br />❑ Mechanical line leak De:tector. Model: <br />13 Occuxxtic lane Leak Detector. Model: <br />D Iaectmnic line leak Detector. Model; <br />• Tank Overfill. / High -Level Samar. Model: <br />❑ Turk O%wfill I High -Level Sensor. Model: <br />• Other ( i t type and tnsuid in Section E an Pan 21. <br />❑ Other (s imiemenuas and andel in Section Eon Page 2). <br />T** IDn <br />T9ok 113-. <br />13 lm -Tank Gauging probe. Model: <br />Q In -Tank Gauging Probe. Model: <br />13 Annular Space or Vault Scasor. Model: <br />O Annular Space or Vault Sensor. Mod& <br />❑ Piping Sump I'[ieanh Seasar(s). Axial: <br />O Piping Swnp t Ttench Semor(sl Model: <br />O RD Sump Scnew(s). Model: <br />D All Sump Sensor(s). Model: <br />G) Mechanical Gine Lrak Detector Model. <br />O Machanicat Ltno Leak Iaetesa<r. Muslra: <br />D Electronic line Leak DcAectot. Modal: <br />Q Electronic tine teak Detector. Mudd: <br />13 Tank Overfill I High-Levr3 Sanson. Model: <br />U Tank Overfill / Higb.Levd Sensor. Model. <br />❑ Other (specify opilmenktypt and model ig Section F, on Page 2). <br />D Other (specify ui ant and model in Section E on Pae 2). <br />Dispewar III: 7%/ Y — <br />Dispenser IUD.-. ite I -- <br />i7 Disperuer Cootsinasmnt Senanr(s). Model: <br />❑ 1Xspaatscr Containment Scnwr(s)_ Model: <br />O Shear Valvo(s)• <br />❑ Shear Valve(s). <br />QDisuser Comtdnnseatt Floai(s) and Cltairn(s). <br />Q Di neer Containment F7oat(c) aced Chwn(s). <br />Dispenser Ei r for <br />[dispenser ID: <br />O Dispenser Containment SenwF(s)- Model: <br />❑ Dispenser Cn ntaininent Semor(s). Modol: <br />Smear Valve(s). <br />O Shear Valve(s). <br />0 Dim neer Containment Float(s) and gnnn(s). <br />0 Dim neer Containment Float(s) and Cltain(s). <br />Dispenser ID: _ _-- <br />DisgaLw M. <br />O Dispenser Coutainrnent Sensor(s). Model; <br />U Dispenser Conudnmcnl SCmxar(s). Mo3ei: <br />U Sheat Valvc(s). <br />13 Shear Valve(s). <br />UDis bw C omeln;:nent Aciat(s) and Chein(s). <br />Q Di ser Ccattaiinnent Floats) and Chain(s). <br />If the facility contains more tanla or dispensett, copy this form. Include infomaation for every tank and dispenser at the fatality. <br />C. Cer'tifiCatioln - I certify dant the utpUpreent identified in this decuonknt was inspedeilserviced in aoeordaaee with the n w0acturere <br />gaiddlmw. Attached to this Certification in Warnmfian (e g. aoanufacdvets° checklists) mmessary to verify that this infurro:ttinn 6 <br />correct and a Flat Plan showing On layout d codialtardog equipment. For any axlulpme®t capable at geueradna such reports. I hsnve a" <br />attacheti a copy of the report; (cheek alf that apply): ® System set-up 0 Ate rm histo ry reutul� <br />Technician Name (print): /'� .�`/ 1'j! �!r Signutun • ' — <br />Certification No.: 7 r i _ License No.: <br />Monitoring System Certification <br />Tanknology-NDE 8900 Shoal Creek, Building 200 Austin, Texas 78757 <br />