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1`11: ��)��i:'•r��i 4�.RfI �.�71,Ili � IINI IIr(..�y Il ��.�1 t <br />1 iu l x, /?I'.allJ,11.L liilh 11.v 117111hI1/n• Vr,If,- nl7'ol/ fwllifI <br />:l ullou ill' l 'hi r! t''hflpk:l• 6. 7. 1 h•rrllh tr;lll il(:h• ('vdv: C71.1pwr If., 11i►1timl." Ti1M _l.i, l 'ulifnr•rriu l'urlr uJ kry;lll.uirutr <br />fill: lium mu:r he tised In douuncnt les(irl;; Mill st:rvic{n , nF munil0hilt, ellnipmwnl. A tit;itaratc_L'ertilil:alitnr nrr.1111E InuRa_ 11_* <br />rrth:Il'l•d fill' � L( ll IZultiliirillL :rytilom comrolyalicl• by Ole (t.;dmician who perliornv: the work. A eupy ulIlii:: lilrm immi 6C Itruvirlrll hl <br />Illi Glnk sy;lvlll nwlicl-hip'n-laid•. Tlw owllrr/(lpclalur 171a"L Submit n Cnity or this form ill (lit: Iocul a); •ncy rr_;nL•rling ( INT <br />lvirhin 30 days ol'tc!:( dulc. <br />A. Genf.:ra) lufilrw:tliit❑ "�' 1� <br />Facility Minn: _ l Ots �[� 's 141,,1 . No.: <br />�o , [ - 1�i`-�—LiT (:ify: Z~c-K-�L�L_ zip: y_fzo& <br />gill: AddreS:: ZL�, •-,,, - .. <br />hacilily l:onlact PUS111: i:unl;lr.I (1(Irtnc No.: <br />NlukrlNlndal or Munilurin� tiystcnr �EE C� � Wit. -of Te:ain�/tierviein2: _ /_t C/ �g <br />li. Inventory of Equinmetit ` es(Y:dll:Crtified <br />c1le It rile mill i1-111Ir hnces In iudicafcypeeille ct ul uncut[ ia.pt cit I/re�ut d. <br />'11u11C IP: _L)l U211C. <br />lit=i"ink (raul!ing Pru(rr•, <br />— <br />Model:._-_ <br />U1 Annulus Spal.•c nr Vaull Selc nr. <br />Model: — ^- <br />ILPipirlgSump/'I'n idlSctiytrr(s1, <br />Madel: ^ <br />U Fill Shull Scllvur(:d- <br />O Mc:chlinicul Linc Lank Delcetiv. <br />Mudd: _ <br />Mmle,: _ <br />�, <br />(J lacetroitic Ulm Lcul: Dcicchw, <br />Medd*., .. . .._. <br />U rani; Owl -lull / t rel,.l.avcl Setisur. <br />Mudd: _ <br />I'. nn Pugu 21. <br />Q 011ier(<pcaify 0I11iptllew tylle and model ill Scr(iuu <br />TtinIt. IU: - <br />U hl.;Tuuk (.inuling Probe. <br />Ntndcf: <br />.._.. <br />L1 AnuularSpatm.. or Vuult Stmsor. <br />Model: <br />Modcl: - <br />U l,ipilia Sump / Trench Sausor(s). <br />Mudcl: <br />-- <br />11 rill tinmp Smisnr(s). <br />Mudel: <br />_ - - <br />U Mrch:uticA Line Lrnl: Delcclor. <br />Mndul: <br />�. <br />❑ 'tank Overfill / High-level Scnsnr. <br />❑ Rlecrronic Linc Leal: Detar,.lor. <br />Model- <br />U -l-ank Overfill /I 1{gJALvcl Sensur, <br />hltulel:. <br />U Othcr (::pcelFy cttllipnlwnt IYPc unJ nus tri in Sncliun E wi l :tpt 7 )• <br />U In -Tani. Gauging <br />1'rohm <br />Q Awltilar-`;pawn or X/mill tic, mi - <br />U I'Ipinit 3ninp / Trench Sr.9lsnr(s). <br />U I"1ill Sundt Seni;m'(s). <br />Q Mcch:u+fctl tine I.c:tk Docalur. <br />❑ Rieclruuic 1 -iiia Lcuk UClcefor. <br />U Tank Overfill / I•li�.h-Lcvcl S,alstir <br />Q Orhrr(sneciN rauinnlen(lync and <br />Nhnlcl: ._ <br />Mocha: _ <br />Milllel: _ <br />Mudol: <br />Mn let' <br />tod.a in Sw.wlion V nn face 2). <br />Tank 11)- <br />LI In-TanPrnhe. <br />Madel: ,. <br />❑ Annulur Spucc ur Vault Scnsur_ <br />Modcl: - <br />0 111ping Sump / Trund+ Sens.11o. <br />Madel: <br />❑ Fill Snmp.swtar(ri). <br />model-._ <br />U MtcKiniral Linr. Irak DLwevir. <br />Mudcl: , <br />❑ FIculmik Linc Leak OcIt-Ultlr. <br />Mudd: <br />❑ 'tank Overfill / High-level Scnsnr. <br />Mi AvE- <br />❑ Other (snecif), uyuilmWilt Lytle Wit Illndrl in St <br />Diypruser Elt• <br />hludcl: <br />Uslicmer COlotlnntell( SensOr(r)._❑ Dispetricr Cuittuinmenl SLnsnr(x). - <br />Shear Vnlvc(s). U Shcar Valvc(s), <br />U Disc-ic;rr Conhtinment Flours) tail Cliain(s). ❑ Dix yrcr CotdainincnL floul(s) and Cltah11F). <br />Dispenser 1D: <br />❑ L)ispcn9crCull(ainlnenl3c+clor(S). Model:, <br />❑ Shear Valvefs). <br />Q C:isflenzr.r Q1tltuinlimIL Mout(s) and ('hain(sl. <br />D [1ir:pun.+erCunlainnlcnl ticn.<nf(si. MlnleL, <br />❑ Shear Vulvc(9), <br />UUlsna•utr f',lutaiilinwn( Flunt(:;} and l:'hain(� sl_�- <br />'II'd+e raeilily clllltains more WAS or dlspellsefs. Copy <br />DiapCnwr ID: _ <br />U DispallSrr ( •nnininment Scusur(s). Model: <br />❑ Slivar Vulve(s). <br />U Di:imaiwr Cutuoiluncnt Flo:tt(s) and ('luiiul <br />C on <br />Dkitemer IU: <br />U Dispe.nsar C•nnminmant Suasuiie). Model:.. - <br />❑ Slle:ir Vulvc(s). <br />❑ Di_pemer Cuntuhlment Flupl(s) and Chaiu( )�_ <br />i. Include lnfermatiun fur every uuik and disrieti ar at d1c r-Wility <br />(,Certiticitl'intl - ! certify tont the aquiplucnl idcrltftled in (him ducumemi wits inspcctctlfselTICCLl in iiecurdwive wifft file <br />ntanuractumrs' gurdefinc,. Attached it, EIris rel-tiGemtion is infonu111iou (e.g. nurntifuehimm' cdletadisls) accessnm-y fo verify Thal (his <br />infurutatiou is cancel mud a 11101 Pints shnwinr. the layout (+f mutlitnrilig crluipmeol. For tiny rquipmeut rtpahlc 0r gcncnitillg such <br />1'cpurlS, t Icnc tilsn attached a tupy afthe report; {clleckalllhal npplv): Rsys(cnl a -u Alarm hisluty report <br />Techriicim Nnme (print): Zq. /Il.itlimll --- • tiit�n:durc: — <br />;;z�,:33 try -ur <br />C erdfleati0n No.: _ 11 3 _ License. No.: (} 1 • c')[. - a - <br />fcsliul; f un+pmly Name: <br />1111011CNO,; `j-�.f%�`r< " - <br />Site Addres, A ZY .��.__ Unlw t•t"I'estirth/Srrvicing: q <br />Pul!c { iif � (17lilt <br />NlnnilprhlgSySteul Cal'tifica(ivll <br />U. l:cslllts of 7'estin�/SeE'v�iu <br />C00 in YVA OT:ZT 90OZ/CT/OT <br />