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i•va VS'9'0*,r> R ('9111"91iCH. Will fl)i -[ <br />f'.rr111,.4/.Jnr•cxlit-Iiiins ll'ilhin/he i,rn riff?1l//is•flirl <br />:I N/llrn•I/1' I Weil Clwlm.v, f,. 7, 1A•ulrlr ('vele; C'ingrrr•r M, Oil'is•irlll 3, 1•ille _rS. ('01011rrirr t ier/r rr/ lir !;l!/rgirrrr.l <br />1'11 is li)lul Illus, be used In docntllent testirlR Intl servicing of moniluriw- elpiipntcni. A selrtrateycrtilit::lliw or.rlyjilrl nnist Ill- <br />1',)r <br />,r <br />Lreparcd Inrcahh monifrlring• •ysIvol control n:ntel. by the technician who pvrl'orim the work. A copy of (his lame 111n::1 he In•avidt•d Ill <br />the t:ltlk SyS0,111 QWller/opun'llor. The owtlCr/operalur must Stibnik a ,:ally AY IRIS AW111 (I) file local agora y IIS I' syslums <br />wirhin 30 days of tc:a (irate. <br />A. 6encral [ufilrtuaiiiit► '""�' <br />rncili(v Nam1:: <br />facility CoIllnet 11crsoll: __bl jm <br />Make/Model trf Monilorio Sy stem: <br />K. Inventory of IC(plinment'1•este.d/C:ertifietl <br />(. ber•Ic tilt apprupriul n�cs to intliatic vptn:ilic cr, ui Invent in,pt•I k d/snvicl d: <br />NU Irl=Tank G$P:HX IN Prubr:. Model: ,•,MAeLL <br />iu Annului }hat.e or VauU SClL4u1'. Model: <br />RL flipillg Sump / Trencil SeusOr(s), Mudol: <br />U Fill tiuuq) Scusur(M. Model: _ <br />O Mccll:lnleal Line Leak Detector. Modul:\ lJ <br />(1 I.Icctrouic Line Lenk Dctectur, Model: <br />U 1-111k Overfill / I IiEh-Level Selasur. Muriel: <br />C1 Other (spa city 4quipnt211t [ypr; �nrl modal iu Staaiun li on Puµ: 2) <br />Tank II)' _ <br />U In=Truk (allgi11g Probe_ <br />--- ' <br />U Annular Spam or Vault SUIL1,01'. <br />Mu(lel:;-.16, <br />U I'ipitig Sump /Trench Seusur(s). <br />Model:❑. <br />Fill Sllmp 5rllsor(s). <br />Model:U <br />Mer:h;I11jeld Line Lcnk Detector. <br />Model=- <br />❑ rit:crronic Linc Leak Detectt)r. <br />Model:U <br />1utk Overfill / I ligh-Level SCIISCW. <br />MOCIrk_U <br />Other (speCif�' et tel )lllcllt type ulld 1110,iH In •S'ectill Piga Z)• �� <br />`J 1310. N(I.: - <br />_ (:ily:,�zip: yszo6 <br />L�' O I)ala cif Tt.-•ain_;/tiervicing: _92-1-9/_08 <br />U Iu-Tun(. Guughig, Probe:. <br />U Annular Space or Vault St.-mir. <br />Cl Pipinr.. \ramp /'I'rondr sclu:or(s). <br />U Fill tiump.Semor(s), <br />❑ Mechanical Une Leak Dcleclor. <br />❑ Rlcelrouic Liou Leak OCICclln'. <br />U Tink Ovcrlill / I•liCh-..Level.Sensor. <br />❑ Orhrr (,pccil'y t:yttiptnau lylx :wd <br />Model: <br />Model: —_- <br />Model: — - <br />Mudvl: <br />.- <br />mo Id: <br />rudra in Seclinn E nn Paee 2). <br />Toldt ID: <br />U In -Tank Gau('ille Prnhe. <br />Model: „ <br />❑ Annular Space or Voult Sensuu. <br />Model: <br />U I'ipine lump / Trenel) Seusor(r:). <br />Mudcl: <br />❑ Fill Sump Sen,ur(n). <br />MOrirl -- <br />CI Mechaniral I Ann I .rnk Detector. <br />Model: <br />❑ Electronic Line Leak Mmelor. <br />Model: <br />❑ 'rank Overfill / Higio cvel Senn. Model: <br />❑ Other fsnecil'v Wu6urne0l tY11c alld 111ndr.l in Sectiuu C uu <br />Dinsrr I U: I FL..,_ Dispenser I I): <br />OQ bisllensa C'0nutirnueul Bonsor( ). Mndcl: _-,_-- �� ❑ lJispeuscr CouWin11leut Scntinr(s). Modcl: <br />Shear Vt11ve0). U shear valvc(s), <br />1:1 Diroemer C'ontrlinmtot Flont(s) and Chain(s). ❑ Di.• enmer f nulaininuot flvol(s) told C'h;tln(, <br />()isperlsel• ID: <br />O Uisperlser Culltainment Sciattv(S), Mudel: <br />❑ Sheor Valvc(s)• <br />❑ Uispallsrr (onlainnit rat Fluut(S) and i'hain(: <br />Di,l)emer ID: _ .. <br />❑ t)ispensur Cuntainl►lrnl Sc,lstll'(s)• Model:. <br />O Shear valvc(s). <br />UUisneueer Conleinnlcllt Flom( ) and <br />-If clic lacilily contains more tanks or dispensers, copy this time. Include <br />DislImserID: <br />U Disparage., ('nnrninment Statsul'(5). Model: <br />U Shen, Vulve(s). <br />U Di:;lx:uscr• Conlallullcnl 1716,100:11A C'lluiu( <br />Dispenser ID: <br />U ltispcnacr t.'nntninmcnl SurasOr(s). Model:_ <br />❑ Shcar Vulvc(..O. <br />❑ Diupcoser Containment F16,100:111,11 <br />formation Ior every talk veld dispensdr W the f moty <br />C. Certification - 1 eLl•tify flint the equipment identified in (his doeun,enl A.us inspected/serviced in accordance Milk the <br />ntanabourers' gulddines. Attached to this Certification is inforinrlliou (e.g. manutrrturers' cllecldivts) necesstiry to verify ilial MW <br />information Ls nlrrccl curd n 1'M 1'1111, sllolving the layout of monitoring equipment. for tiny rquipnaent c:lp:thlc of generating such <br />I'cpurls, it have also ;IttacheJ u copy enlf' the report; (trbeck n111krr1 apply): � Syslunl a -u Alarm history repro t <br />Technician Name (print): /IL,�r�mD ___ . Signature: -- <br />Certiftcation Nu-: _ /lS3 _ License. No.: 0 •� C-1 - j la - <br />'l'enting Cbntp:uly Nanle: %� tY �LD1�'=/—�� <br />L_._._�--------- - Date uf'I'estin;�S�rvicing: q 01 /0-5Site Address: _1"Y <br />Page I 6f of/n+ <br />monitoring System Certification <br />D. ltccnits til'7'ctitin�/Scf vyiiu <br />coo[j xe3 01:i:T 900zic1i0i <br />