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<br /> 'IV[I ITY 7r•°S IM;0I; I'A""11(;1I1)I11V1) Til MAWA7 A1'►rNft)AA►,I'17,T7►7v
<br /> P©sl +Dfflce HQX 36 77wrrrton, lir, V568G 209 79 2`�rAX 794-0112
<br /> !n� f
<br /> r Ge))el,ni !nt'rtrrl)f1(iritt OCT 2 1 20OZ
<br /> NY
<br /> Site A1lrlrrss: Cil1..
<br /> Filfiiity('rinlnct Person- -eL F�Vf�f7 P• s "!
<br /> 'to nln4f IIll r,nr lira, ( 1
<br /> Make/Mnilrl of Monilr,rh, ; strru , 0 ---
<br /> ------_.._��, Ilnrr ul Ir•slinl!LSrrvirinl!: �l�/�1���
<br /> n. 1))VPlltrrt'3' r,f r�.rlrti�rnlr�l,l '1'rsferllt 'r•r fUirrl
<br /> Check the Oppropthle buxes to Indicate specific a ul n,ent 111911171 147111-tel$1r17d:
<br /> Tank 11): Y,V
<br /> ❑ in-Tank tine m i'rol,r. III: le.
<br /> R� R hfnrlrl' ---
<br /> U Annular Sl,arr or Vanlr SrnSol,j: 'r'nnk(tnnRinlr 1'Inhr
<br /> MuJr L nulnl Sl,nrr o, Vnnlr,Srnenr
<br /> U riping Stin,p/'r'renrh Srnsnr(l) Il4nrfrli0qm
<br /> U nil SnrTll,Scnrnrf+l 'i11RSung1/'r'rrl,rrl5111111+Srntr,l{,I.i,rnk i)rtrt•inr. Mnl I Q P_lectronir Line.Leak Detrelor. 1 iodrl: rilnnfrul Litre I cnk f lrirrir,l. Model: fii al:]ti y�J
<br /> U Tank Overfill/Iligh-1 evrr Senlnr. h1wirl! U 111"ll"nic line I.rnk DrIertnr• Model:_
<br /> ❑ OIfter(specify equip rnent t . end tncxlel in 5ectiuu uu I°n t Z . U Otherr s ecifl/I IugllTrn 1111!Srr�nd rn+adcl in S---ion I?--11 P e Z ,
<br /> Tank ilh A-,','It-
<br /> ❑ In-Tank Gauging rnrfir., �.__-�---h4rnlrl, -� Tank 111:_�------`-._-_ .-�_
<br /> Annular Space or Vault Sensor. Minlrl '__ `.__-�._ U In-'look t.rm,Riog mole. Model:
<br /> [UU
<br /> Piping Stamp/Trench Srnenr{s). hlndel U Annular Spurr nr Valli(Sensor, Mrlslel: -
<br /> U rill firmtt' ensorSeri�Sr E CbE�J�} U "'11"19 Strnip/Tirochnsn
<br /> Srrls).
<br /> 13'�eehanical Lint Re, Mixlel:
<br /> Ls 1�71rrrrl U slimil Srn.ent(s). Mr,tlel `
<br /> enk i)rlrelor. Mnrlrl: .�=,+�f -`-`-' fill ;
<br /> O Pl"onic Line Leak Deteclor, Model: U Mtrrl,aniral Hill-I rnk ]lrirclar. MrKlel:-�
<br /> Tank Overfill!High-1 evel fienam. Madel U Pleetronic Line i.rnk r)etrcfor, Model:
<br /> Fer{s self ui lrtent 1 and nrlxlel h,Sr;lio+l Z nn I'll c 2 , U Utherf e'ecif ct uRi Ilrr tri fiePC 1in. Mollej:
<br /> ,Usnnd rrlerrle!in Section E on Page ,
<br /> er 11): .
<br /> rienlier Coniainnunl Sen11misi. Mrlrirl' J1lalrrnerr II>; "� t� A-1
<br /> ar Vnlveis). U I tillwilnet P°n1,1aillorrrrl firitlol('l). MINiel.
<br /> ser Cuntaimnent rivets erid t'hnin(s)tl U ,Shrar Valvefs).
<br /> U Uis,tatser(unlairinlctll fluei(s el)d Chsin ser rl): moi"` ('ensrrCanfainment Sencnr(l). hiorlrl; ()Islrrnsrr f1);r Valve(g). - U lrispenset Cnfainnlents). Mriel:
<br /> nser Containinenl Tloat a slid r_'hninis) `^ , U fihrnr Valvef1)
<br /> U Vis►eraser(:unlsinfrtenf fluaf s sod C71ain a , ¢' _er 11);enserCnntainrnrnf Sensur(sdel U t)isl,enscr f'rnllniltrrtrt Sensors}. Mirilel;
<br /> r Vrilve(s).nser Cunteitunent rine! s earl Cllailt s U fif,ent Vaive(s),
<br /> Commiltrilent
<br /> ser
<br /> "If lite facility contains rune tanks or ifispensrrs,rtlpy piie fol n, lilrlrtdr inforn niiont(firr every lank an1,0 and
<br /> LW—d diRpenaerr 111 I ei facility.
<br /> C. i certify thnf!hr rgrllprr rrlf Irlrnflllrll Ili Ills 11111r1Trrtrut wa.s Insprrtr+llarrvlrrrl In arcnrdance will the nanufaduren'
<br /> gulddtrtea. Attached to this ['erliflcafl '
<br /> Ov s hirnrinnflon wit. martufaclurrrrr' chreklisflr) nere"Itry to verify that fhb Intorm ition is
<br /> correct and a Pint Plan showing the layntsr ;nrntlltot Irlp rgolptnrnf. For any equlltinenl rapahir or generaling such reports,!have abo
<br /> ■ffarhrrl If mpy of the repna (rlrrr rail 171 al~/,ly) U St•wlrm arl-rap
<br /> Techrtivian Nnrnr(rnlnll' U�rivk, nr reptivrl,
<br /> C"rFlif'FI•>,Pinit i`Jn.: ��^<,✓!,:j�-Q��� �"- '
<br /> 1 ire.nsr No
<br /> M1lnniforfo� Stsfrrn ('rrllficnfinrt I'ner I of )
<br /> t:_'Vtl M
<br />
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