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Afforbin-Tr$ <br />QUA/,17'P1'F..C77Ar(;Of'1rnrnFRr;R(1UNll7A7VK.VATArf7)7tUAAfrRATFr.S' w <br />Post Office Box .16 Thornton, Ca EQ(PA 94-0102 rAX 794-0112 <br />f JUL 3 12002 14 <br />General Infonnaliun <br />F <br />ity Name: �� r k j[ �(1 `' L l( (� V y Y7 ENVIRONMENT HEALTH <br />Site Address: _ � W , _l..k a i P'•P.Y' iti) a r PERMITWVP�Afm <br />,. �. al_,. Zip: <br />Facility Contact Person: SN 1- r .7dot- 60+ r II� Conlnel Phone No,: /o <br />Make/Model of Monilooing System: Vpp�� h-�a`(V U f �� S ­15'�'v 11111,nf'1'rsling/Servir•Ing: 1_ a -/_6Z <br />11. Inventory of Itgoilnueill '1'e.SlerlJ(*Cl liliet <br />TSO 11): N, Vl <br />'Tank Ilu: <br />K <br />IN In -Tank Cmn¢ing Probe. <br />Model- n+°1'[6' / /!./ P-7.3 <br />_ <br />W In'I nnk Oangine Pmhe. <br />Model:a /6/7 �� <br />U'Annular Space m Vault Senanr. <br />Murlel: ,Q 7 q +j 3 9 O -9 i0. <br />L? Annular Space or Vault Sensor. <br />Model: 07 4 <br />(d Piping Sump /'itenek-geawM#1. <br />Mmlrl! G?1a/H3 riD -..fit <br />UrTiping Sump /lYenrlr9enwwfa). <br />Model: 07 -'7 <br />❑ Pill Sump Sema(.), <br />Mmtrl <br />U Pill Sotop Sena.. (#). <br />Mlalel: <br />Vechanfcal Line lank DrIertm. <br />Madel. ,. <br />.J� <br />U Met hnnical Liar leak lrefectnr. <br />Muriel: <br />ectmnic Line Leak Deleclor. <br />Model! ..-Qa70 • V 07.. <br />Ed-Pleclrnnfe Line Leak Detector. <br />_ <br />Model: :12212'8 74 p0%, <br />O Tank Overfill / High-Irvel Sensor. <br />Model:__ _ <br />U Tank Overfill / Iligh-Itvel Sensor. <br />Model: <br />❑ Other if equipment t and model in SectC <br />iun on Poi e 2). <br />U Other (specify of ment type and <br />model In Section 8 on Pow 2). <br />Tank ID• 9 / _—__u <br />e___-.. <br />Tank IU• <br />❑ In -Tank Gauging Probe. <br />Model: /17ft <br />U Im'I'ank Gouging Probe. <br />Model: <br />❑Annular Space or Vault Senanr. <br />Motais ._Z?1340 - 'f=iD <br />U Annulnr Space or Vault Senanr. <br />_ <br />Model• <br />❑ Piping Sump /Trench Senaor(s). <br />Mmiri 079 H 37?b 7oB' <br />U Piping Sungr / •french Sensor(s). <br />eL <br />❑ Fill Sump Sensor(s). <br />Mrdrl.. <br />U Pill Sump Srnaor(n). <br />Morlel• <br />❑ Mechanical Lane Irak Detector. <br />Mixtrl' <br />U Mechanical bine 1 elector. <br />Model: <br />0 Mechonlc Line Leak Detector. <br />Modrl <br />U P.lectronic . .enk Detector. <br />Model: <br />❑ Tank Overfill / Iligh-Level Senanr. <br />MwIr+ _ <br />U 'la,nk-frierfill / Iligh-level Semor. <br />Morel: <br />❑ Other (specify equipment type and model in Section L' un Page, 2 . <br />U'Zltrer (orrecifY equiPmeril type aid fnadel in Section Boo Pass 2). <br />DNpereo r ID: I 'i' oz:_ .. _. <br />_ . .. - <br />Dlaperraer 11): <br />U l)iq"orr ('nnlainneni �rllalnfa). <br />Modrl• <br />U Digemei Coadainnent Senanr(s). <br />Morel: <br />G?'Shear Valve(s). <br />l hror Valve(s). <br />"xiseaster Containment Float(s) and Chain(s). <br />W15ispenser Containment Float a and Chain(s). <br />Dispenser ID: of V (o <br />Dispenser ID: '-� Y" <br />O Dinpeatett Containment Senenr(al. <br />Morel: _ <br />U Ui#penett Comtainnenl Senanr(#). <br />Model: <br />O Shear Velve(s)._-- <br />Cd Sllcar Valvefs). <br />fi'6i sox ContWitment Float(s) and Chain(s). <br />U'6ispenser Containment floats and Crain a . <br />Ddperoer ID: <br />_ / <br />DI#penser 111: <br />❑DlspeneaContainment Sensor(s). <br />Mond: s/' <br />UDispenserContainmentSensor(a). <br />Model: <br />(3 Shear Valve(s). <br />" <br />U Shear Valve(#). <br />❑ ser Containment Float(s)orad Chains <br />. <br />❑ Dispenser Containment Float a and l pain s . <br />-....F racnny .."assns nano moan or Wirspcnsern• copy Wins lono. mcnrne mlonnnuon for every lank and diapenntt at the facility. <br />C. Cerflneatioll - i certify Ilial the equipment Identified In till' doemnenl was Insperled/servlced In accordance with Its maOlbtMaB' <br />guidelines. Attached to this Certification Is Inforroallon (e.g. manufacturers' checklists) necessary to verify est tYa Yhat•atlats Y <br />correct and a Mat Ran showing the layout of menitoring equipment. For any equipment capable of generating such raper% I Iris Yea <br />attached a copy of the report; (shads all rhaf apply): U System set -op ❑ ar I 1 r report <br />Technician Name (print): C _PN , n N•i Q <br />Cerliffcslimn No.: _ "Gf/G? OG OJT l.irl•Irar Nn.' 0 <br />Testing Company Name _'.may+b_��k' �PG <br />- /�C/_:. flume No • � <br />PRM, 1 of # 0"IMonitoring Syelrm Certification <br />