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f farba-AT <br /> rip <br /> 7 <br /> `QNIALI"I TFSWNG OF UNI)rRf�ROUNI) 7ANK.SAT•AI%lYJllf�iil(l.E 4TF,.S' <br /> t <br /> Post Office Box 36 Thornion, CU. 95686 (209) 794-0102 FAX 794-0112 <br /> Genera! Information <br /> Facility Name: . F , Hid No.: <br /> il <br /> Site ridress; / g. <br /> --L 1G?.-�= p'� "(' .. [ fly: _d �, -- — Zip: �f <br /> Facility Contact Person: _ cS_ e U Cownct I'honr No.- (-,;20_`1 <br /> Make/Model of Monitoring Sysrcor:- 0 P14 yJ � TL x-666/ i►rile of'I'rsiin�*/Scrviring: L1_r�r OZ <br /> U. Inventory (if H,quipntlent 'l'eSletl/('er-lifit-tl <br /> check the appropriate boxes to Indicate ecitic a ul trent Inspected/serviced: <br /> 1(3 <br /> ank ID: e Y'D 5,�'v� P Tank ID: Qi_a!—� V,0 <br /> in-Tank Gauging Probe. Madel: --. - LJ in-Tank.Gauging Probe. Model: <br /> Annular Space or Vault Sensor. Mrxlrl: }1 t y� p�r�lir l fnf U Annular Space or Vault Sensor. Model:_0+oa ry j i esu '�nw7 <br /> Piping Sump f Trench Sen.sor(s). MndcL _ U Piping Sump/Trench,Sensor(s), Model; <br /> Fill Sump Sensor(s). Mnrlrl: U till SrnnP Srnsnr(s). Mtxlel: <br /> ❑ Mechanical Line I enk Deleclor, Model:_�_ =0 0 U Merhnnieni bine Leak t?eteclor. Mtxiel:E_(T� <br /> Q Electronic Line Leak Defector. Model: __..-..__ U Flecirrrnic Line Leak Deteclor. Model., <br /> ❑ Tank Overfill f High-Level Sensor. Model: „- U Tank Overfill f Iligh-Level Sensor. Model: <br /> LIOther(specify ui ment type and model in Section E on Page 2). ❑ Other(specify ui ment type and morcel in Section E on Pop 2). <br /> Tank 111); Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: --_.---` -�- ❑ In-Tank gauging Prnbe. Model: <br /> 0 Annular Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensnr(s). Model: . , _ ❑ Piping Sump I Trench Sensor(s). Madel: <br /> ❑ Fill Sump Sensor(s). MINiel: -.-- _ U Fill Sulr►p Sensnr(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: _ U Mechnnical Line Leak Detector. Mulct: <br /> ❑ Electronic Line Leak Detector. Model: _ _ _ - ❑ Flectronic Line leak Detector. Model: <br /> Tank Overfill/High-Level Sensor. Madel: _ U Tnnk Overfill f Iligh-Level Sensor. Model: <br /> ❑ Other(specify equipment t and model in Section E un Pae 2). U Other a eciF ui ment t and ruxiel in Section E on Paste 2). <br /> Dispenser f11: id Dispenser ID- <br /> ❑ Dispenser Containment Senanuls►. MotirivVIO' +.` P�at3r U Dispenser Coulainnlent Sensot(s). Mollel: <br /> © Shear Valve(s). U Shear Valve(s). <br /> ❑ Dispenser Containment Fioal(s and Chain(s). ❑ Dispenser Containment I�loat(s and Chain(s). <br /> Disperser 1D: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s), Model: T. ❑ Dispenser Containment Sensor(s). Model: <br /> O Shear Valve(s). U Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). <br /> Dispenser ID: Dispenser 11): <br /> ❑ Dispenser Containment Sensor(s). Model: _ _ ❑ Dispenser Containment Sensor(r). Madel: <br /> ❑ Shear Valve(s). ❑ Shear Velvets). <br /> ❑Di nser Containment Floats and Chain (s). ❑ Dis inter Containment Floats and Chain(s), <br /> •if the facility contains more lanks or dispensers,copy Ihis form. include information for every tank and dispenser at the facility. <br /> C. Certification -I certify that the equipment Identified fit Ills document was Impeciedlserviced In accordance with the msjajdadarere' <br /> guidelines. Attached to this Certification Is infnrnmilon (e.g. manufacturers' checklists) necesstary to verify that thio Intatutatlart it <br /> correct and a PIM Plan showing the layout of monitoring egnipntenl. For any equipment capable of generating such rgxwb,I have Abe <br /> attached a copy of the report-,(check all rherf applv): U SyMern set-tip U larm history report <br /> Technician Name(print): /_f' <br /> Certification No.; a] , 77 p f /f �!(� 196,-)15 I.ir osr No,: <br /> Testing Company Name: <br /> 1'nRe i of i 63!01 <br /> Monitoring System Certificnllon <br />