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Site Number Date ( ll <br /> Ali. . k Senors <br /> n*1 r)'�� T ;senor no! <br /> TeniiB� t C BTPStm�Semora'" 3 FnISI�pkII�s�or 3�f�',-'IYf:.;u � f.'.:�3"Y., vrA ".What tlwsaesorbfor <br /> Order per Write In Manufacturer S Model No. <br /> tank UNK=Present but cant determine <br /> monitor NA-No Sensor <br /> ' 208 2-- <br /> 2 z -CCI 1 sL -uH i�3�o -2oa ?� 3�e� — � 4 <br /> 3 7yf3eo °g -7q�310 - � -z- <br /> 4 <br /> 5 <br /> 6 <br /> £ lfodd lboober Serial N..'w v brawl Det. ft.of No�os No of#fetors sim d Typs D uglded s <br /> II a`g ��udf� �.�• �'P%� ,ae s �nricr.0 h �(etencee <br /> 6=Bennett Write number Write number Lighted TV Systems <br /> Write in the year M=Mechanical Valances on integrated in <br /> l2 or 3.4. G=Gffbarm of noes per of meters per P=Pressure <br /> etc W=Wayne Write in Model Number Write in Serial Number the drspertser eras fueling fueling E=Electronic S=Suction Dispensers? dispensers? <br /> T=Tokheun Irsfafied posflon position NA None <br /> Yes or No Yes or No <br /> t C c'-j't uQ +1 D <br /> C hmeA o <br /> C Nom- . a�� �meno, ► 23 U t3 oUb <br /> Cornrnerft on any damaged/defective equipment J L a .. <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> issued 42/27/2017 Page 5 of 10 <br />