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Site Address: c�i�Or 1/- r 4t1 r <br />Facility Contact Person: �/ N h t '7�'� t" b4' 11 1� <br />Make/Model of Monitoring Syalrnr: Ve p 0/,P t-'6�U O <br />R. Invenhrry of ICyulpment'I'evlr•d/l'erlil'icd <br />r� nC �. 7.i <br />f Tj. S -­(jd�rz> Itmr nf'I'rsling/Rrrvicing: <br />-- —nrcc ur n ",Ina ecaeWeer vtreat <br />Tsylk ID: VI. <br />_ <br />'Tank DIC <br />k <br />fJ In -Tank Gauging Probe. <br />UrA <br />Mtdef• "IA / / `/ 47._3 <br />_ <br />W1n-Tmlk Oeilging Prolm <br />Madel: /G/-7 <br />nnohr Space or Vault Sensor. <br />Memel: _0 T9. , B !f <br />9 0 - _a¢ <br />IT Annular Spatz or Veull Sensor. <br />Model. 07 <br />Gr Piping Sump /'FrewekBaNsnNs). <br />Model!gajH 3'Y a -.?O r <br />W"i•iping Sump / TwarlrlenslwM). <br />— <br />Model: <br />O Fill Sump Sensor(#). <br />M'"Irl. <br />U 11111 Snulp Sensna(R). <br />_07 <br />Mallei: <br />"edaenicel Une leak 1 elector. <br />Madel: <br />U Mechanical Une 1 enk I irleclor. <br />Madel: <br />Ed Blectmnic Une Leak Detector. <br />Madel: Qa7(o. 90-L <br />U-bectmnic Une 1_eak Detector. <br />Madel: ;'f,Ob 76 ^• 00Y� <br />O Tank Overfill / High-Irvel Sensor. <br />Model:_ <br />U Tank Overfill / lilgh-1_evel Sensor. <br />Model: <br />O 011ier uifit t olid model in Section E on Page 2). <br />O Weer ($P@dfy GQU[Pment tYPO and <br />Mudd In Section B on Pao 2). <br />Tank IDt 9 ( u-�--__ <br />_. _..... <br />Tank IM _-- <br />O In -Tank Oeuging Probe. <br />Model: _ ,n.OVOL <br />U In -Tank Uanging Probe. <br />Model: <br />O Annular Space or Vault Sensor. <br />Model: 074'[340 <br />U Annular Space or Vault Sensor. <br />_ <br />Model• <br />t O Piping Sump / Trench Sensar(s). <br />Motlel: 079 H 346 7.e8' <br />U Piping Sump /'Trench Senenrta), <br />e1. <br />O Fill Sump Sensor(s). <br />MINlel. _ <br />U 1-111a( <br />t Sump Senssl. <br />Maki: <br />O Mechanical Une Leak bcteclor.Mold: <br />_ _ <br />U Mechanical Une 1 Armin. <br />Model: <br />O Electronic Une Leak Detector. <br />Model: _ _,.. <br />U F.leclmnic .ak Detector. <br />Model: <br />O Tank Overfill / lligh-Level Senate. <br />Model: _.. _ _ <br />U i'n ell / High -1 evel Senior. <br />Madel: <br />O Other Is acif i t t and toodel in Section E on Pae 2 . <br />U bars If ul t 1 ad tsmdel M Section B on P 2). <br />Dispenserm: ! y -'.z- <br />- <br />Dispenser 1W. -a D►_ -y <br />U Dispenser Contaliumenl h'rasso(s). <br />Mixtel, <br />U PINfirnRer f'ImIRi1111M1/1 irnmr(#). <br />MINIM: <br />GYShear Valve(#). <br />I9Hear Velveo). <br />_-- <br />"spenser Containment Flosit t and Qlain s . <br />W-1671spenser Containment Floel s and Chain(s). <br />Dlsperm. ID: dc4— (9 <br />INspemer ID: <br />O Dispenser Containment Sensnr(R). <br />Mokl:__ <br />U Dispenser Containment Sensce(s), <br />Model: <br />O Shear Valve(s). <br />"'wenser <br />Cd'Shyr Velvets). <br />Containment Float(s) and <br />Chain(s). <br />"ispenser Containment Most(s) and <br />Cham s , <br />DYpenser ID:I)leperaer <br />/ <br />III: <br />13Dispenser Containment Sensorts). <br />Madel: <br />U Dispenser Contaimrlat Senace(s). <br />Madel: <br />O Shear Velve(s). <br />/� <br />U Shear Valve(#). ' <br />❑ ser Containment Floats endChei <br />n s . <br />❑ Dispenser Containment Floats end <br />Chain(s). <br />cif the facility contains more leaks or di#pensers, copy Ibis fontinclude information <br />for every tank end diec neer at the facil' <br />IIV <br />C. Certincaliob - I certify that the egnlpmrnl Identined In this dorurrlrnl war Impect"Werviced In accordance with the maardktann. <br />guidelines. Allached to this Certification la Infnrnutinn (e.g. mannhHuren' checklists) necessary to verify that th4 fafotmsUra Is <br />rnrreef and a Mol Man showing the layout of monitoring rqulpmenl. For any egnlpmeM rapshle nrgenerating rash reports, 1 draw abo <br />attached a copy of the repo?; (rkecg off that apply): U System Rel -cop ❑t ar 1 r report <br />Technician Name (print)! � 0 ,I.Y.h Yn,� _ SiPosture: �(�fg�_{ry <br />Certification No.: _ �/(�? 060..5- I.Drrnar No. - <br />Testing Company Nmne: /}-� i '+ - - el <br />Mon Iforing ,gl'stpro ('ertlficntloo <br />_ ... Phone No j o !_.) <br />I'ngr I of <br />eitp <br />