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(1(UAL17T 7'T:S'7ING(W'l JA+l rF1r(,1?0f 1N1) 7ANA'. 1� FSP Post Of�i7ce flux _6 7"horriforr, Cis. 9. 686 (zl�� 79�4�rl�a�o� r•A Y 794-0 ll2 Gellerrrl Irrlilrnli+linrr2c) , ENVIRONMENT HEALTH Facility Nna+r: A, ir_-e r�vd , yt PERMIT/SERViGE$.._._ _ reltlR. Nis.:___ r a Site Address: ....... {dI'�'t'� �3 u(' Q s,�' �( ['icy 1-nlc Zito: d� Frorilily Conlncl Person + !" --_� ('nnlnrr 1'114jnr N,,. f - Mnke/Kimlel of Maoilm ing Syslr•+,+ 1 / ._. _/_(�- _ ___.._._ _ I+nlr rel 'I r^.iinf+/4rt viriol!' l/ fL l� _ it. Ir+vr111411.3' 4117 Ic.4141I1elowerl '1'l-Mell/l '0 1 title tl (deck the oppereptiale hoata to Indicatespecific a ul eoneat lus rrttedlnr++Ited: Tank 111: R lj Tank iIv: - - --- '✓/ '-r' ❑in-Tank UnNRiog Probe. Ma,rlrl U in 'fnuk(inuRh+R 1're,br – - Model: Er—Aronvoloof Sparr or Vnulf Srnsot. nia,irl• 1 _r.. t-1-7ln„utn+ Sprt+re tie Vnrrlr,Senses. Model: — `� –-5 I�iping Stetnp I Trenrh Sensnr(si. Model- (I U'l'ipinp.Sunq+I'I•rrvich Sriltor(s). Mntlel:_ S !w-g U till Surra+SelvInr(e), hin,lr'l' U 1111.Bacot+SruRen{+). Mattrlt_ .. U Mechanical I Jim I rnk I+rtrrtnr htnilr•I. U kirrhnnirnl Liar I monk I lrlertnr. MrNlel: © Fleelronir Line I,rnk 1lelrrltn. Mrnlrl: U 1?Irrlrunlr I.Inr Irak l/rtrr'rnr. mixiel: _ U Tank Overfill/high-Level Setigw. Mearirl: U 'funk(lvee(IR I I llgh-r evel Rrrlar+r. Model! U ()doer(spedry equipment type tend model in Sectiuo E tta 1'n e 2). U Odier(specify ui nuenl type and ulude!in Section E Ort PW 2). Tank ill: 'hank ID.- ❑ In-Tank Gauging Ptol+e. ModelU In--I'mTk Ganging 111r,l+e. Model- 0 Annular Space nr Vault Sell-tell. Model. _— _ U Amm1aT Spare w Vault Sensor. Madel:_ ❑ Piping Sump/'Trench Seneoi(sl. Mnrlrl:. U Piping Smsvp/'french Smi-mr0). Moitel:_ U till Stomp Sensar(s), hirNlrl:. U Will Stomp Srnsorle) Moolel. _ ❑ Mechanical Linr Renk Delerlot. Maelrl' _ U Mrrlrnnicel Liar I rnk Orlrrtar. Model. ❑ Elecitonic Line Leak Delerior. Madel: _ U Firriroriic Line Irak 1leledw. Model: — O Tank Overfill i Iligh•i_,evrl Men;tm. Model- U 'Irt,+k Dveir'rll/lligh-Level Sensor. Moilel: U OTher(r ecif equigunent type and model ht 5eciiutr U vu I'n e 2). U Ulher tsCecify equipment anent 1 and trtudel In Section E on Page 2). Dklpirmer IM 10trtrnvrr ID: U DiRpenRer Ci minin tem Srlttmilt). KOH' U I IiRlletlorer CeilNnitUltrilt StllRlil(R). Mfo(Iel: ❑ Shear Valve(s). —_ U Shear VRlve(s). ❑ Dispenser Containment Flunl s and[:hnin(s). U Llis censer Containment Floal(sj and Cllain s . Disprower II►: _-_-— Iliryretrser ID:- ❑ Dirpenner Containment Sensor(s). Motlri: - -- . U l iispenser f'enolninnlral Sensrn(s). Model: ❑ Shear Valve(R). U Mirror Valve(%). ❑ Dir neer Conlainrneni Flual s end Cllain(s). I U Dispenses C'untainrnenl llual s and Cliain s , Dlapetrser III: .. Ilicperrxer 111:-._ ❑ Dispenser Containment Sensoi(s). Martel: ,. _ U l)is)xnser('nnrninrnenl Sensat(s). Model: ❑ Shear VRlve(s). U Shear Valve(R). UDispenm Contairunent lluat s avid Chain (s). U Dispenser Coutaiimvent Cluat s and Chain (s). *If live fatilily cnntainR rune tanks or dispensers,ropy Ibis (en+a Inrl+F[lr IN(arlr,alllm GN tufty Inllk aT11I 111EprnRer RI tlxi fae(I1ly. C. Cerllnorn hill -I certify that the rgrApnrcnt Irlrnllnrd hr(his ill+run►rnl was Irnprrlr+VRervlccrl In arcnrdance wilh the raamfecturen' Ruldellnew. Attached to this Certincallon lR h+fnrmistion (e.g. mamrfaclurerw' rhecklislrr) neemary to verify that tib it ermstlon b correel and*Plot Plan Rhowing itie layout or mnnllar hip rrrnllmwill. Fell,any erpdpersent ropa lilt of Rereerat(nrr sneh reports,1 Tuve also attached a mpy nr tlhe rr1''�orl;(FhrrA all rhol errAr1. )! L1 Systivin Re(-roll U tttr tr h Rloty xt,p4lrt Terimician Nosullr(r+r�i}nd' ✓! ! YY/ f71 Sipantinr ('rrllfir'ali+Yll Nrl.: ` �� I h vii-ty Na Poore 1 r+( 1 alibi INr►nllnriar(Si'Mrnl ('rrllnrnllnn