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f forbu.~ 4LA i h�. HEAU h cRKE 'QUALITY 7FS'77NG OF I INlW11GROI NI )l 74NK.VA7'Al,{�I�J�L411/� ItcL7�s' �3 Post Office V'Genernl Inro Facility Name: T Site Address: 7 FAX 794-0112 fildg. No.:_ Facility C'nntncl f ersnn: K a ( Conlnr•t I'hnnr Noi.• ( ) Mnkr/Mcidel of Monilrnink Syslrm- f k,c-An i1 _.T 1 1111 f% 1)111v c11 'Irsliog/.Sriviring: / 5 / 3 11. Inver111n•y err helilipnu•nl 'I'e:atell/1 'erlit i1•tl Check the oppropriale boxes to Indicatespecific a ul noen( Ins crclydhei ►Iced: S P ).. Tsnk ID: !-� !^ i-- 111: J r' t� ❑ In -Tank Ganging Probe. Mn�lr I m at <, _ Tnok (merging 1'rnbr. O Annular Space or Vauh Srnsor. A(odrl: T 4 l� F 2 S FA1111111mSpore or Vnoil Sensor. Model:O Piping Sump / Trench Sensor(s). Mndrl: T` S (� U k S ng Sump /•[troch Sensor(s). Model:T b{ /U Fill Sump Sennnr(i). �(oilrl' Snmp Srimm(i). McxlrlrU Mechanical Line beak I)rIm-im. Modrl: rc•hnnicnl Litre I cook DrIevim'. Model: - O Electronic Line Leak Detector. Model: U Rlrelionic bine Leak Defector. Model: O Tank Overfill / Nigh -Level 3rnsnr. MmIrl:. U 'I'mik Overfill / I ligh-Level Sensor. Model: ❑ Other (specify ui ment type and inu del in Section E cin Pri a 2). U Udder (specify ui ment fyjM and model in Section E on Page 2). Tank Ith Tank 11)• ❑ In -Tank Gauging Probe. Model:- _ U In -'[rink Gnoging Probe. Kindel- ndel:O-Annular 0- AnnularSpace or Vault Sensor. model. U Mnndnr Space or Vault Sensor. Madel: ❑ Piping Sump / Trench Sensor(s). Model: U Piping Sunyc / •french Sensnr(s). Madel: ❑ Fill Snn)p Senanr(s). McxleL• . U fill Sump Senxni(s). Model: ❑, Mechanical Line Leak Detectnr. Model: U Mrchanical Liar I enk Detector. Malel: O Electronic Line Leak Detector. Madel: U Electronic Line Leak [)elector. _ Madel: ❑ Tank Overfill / Ifigh-Level Senacn. Model: U Tntik Overfill / Ifigh-1 evel Senior. Malel: ❑ Other (specify ui ment type and model in Secliuu E un I'a e 2). U Other (specify equipment ment t pe and model in Section E on Pae 2). Dispenser In: "'2-- Dispenser ID: "''; y_ ` / U Dispenser Ctinto inn)rm Srimm(i). Mcnlr I' T- c, a; i• / U Diipenset Containment Srnim(x). MlNlel: VQ - 1-47, S ❑ Shear Valve(s). U Shear Vnlve(x). ❑ Dispenser Containment float(s) and Unin(s). U Dispenser Containment floats and Chain(s). Dispenser ID: '_� )L (I Dispenser IM _ -3 '1"� ❑ Dispenser Containment Sensor(s). Mndrl: T s �c 5 _ _ U 1)ispenxer Containment Sensor(s). Model: �` > do v �� ❑ Shear Valve(s). U Shear Valvefs). U Dispenser Containment Ilost(s) and Chain(s). U Dispenser Containment float(s) and Chain(s). Dispenser ID: —.-- . _-.. .. 1)Ispenser ID: ' ❑ Dispenser Containment Semor(s). Mndel: -_ __. _.. _ ._ ... U Dixpenaer Coutninment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ❑Dispenser Contairunent rlont(s) and Chain(s). U Dispenser Containment Float(s) and Chainfa). 'If file facility contains incae tanks or dispensers, ropy Ibis form bn•Inde information for every tank and dispenser at the facility, C. Cerlir enflon - 1 cer(Ify that the egnipnrenl Idrnllfird In this doc"Inrnl wax ImpeclelVservicevl In accordance with the rnemdecturers' guidelines. Attached In this Certification Is Informnllon (e.g. msnureef nrers' checkllsta) necessary to verify the! this Infollmetlon D correct mood a Plot Plan showing live lnyom or mnntlorinR rgnlpntenl. For any equipment capable or generating such reports, I have also attached a copy or tiro report; (eherk all t o/opp/r)s U System sell -1111 U lair 1 hl t'►r repfir-1 fechnicimn Nnnrr (prinl): V 1r' `l' V t ;:1c1� Signnlmc: r ) �� 'ertific align No.: r' l w 1Li "' J I .imam- Nn.• Pnge I of 3 03/01 1nnllnrinR Syslrm ('erllficnfinn