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<br /> 08/'29/2008 11:04 FAX IN01/008
<br /> J .r t .., /:iIFl.rn;'c,;�,.r:ur.. il';uur:..., ..;,rr.•rn ',rri!,u'„i,,
<br /> IWho!in. r•'ut!rl; 1 'irNl vr'r ri• . ld'r I r, r
<br /> r// ar i,-'.rrl:'n• '.,r.. 1 lr,rhir'r ,, '•:'l.':;t ''orf .lir/r•r':!1• ..
<br /> illi!; )6I'I11 IlIlISt It,: Iltictl 111 lltu'IlmCnl ll'!illnr� :111(i !:CIVICMv. tX 111(mitorb !, equilinimlL A Ngi;zr;lh: k'a:r(ilic"Itioll tll 117UI'r: liltl)a !n_
<br /> I)IUnaiCd Il)I'(;tialIllulllIm-in_!sysleni.conlrol_ an n(:I I'll the teehrliciall%vlw perliwim;Illu wtrrk. A Colly t,f,this lion musl hr.I,I'r,vi(Ir,! ,•.
<br /> the lank syslrmm owner/operator, flu: owner/opunim must suhmil a Copy of IN!; farm to the local :u t nt:y rl tariatin '. (ISl”;«!;tool;:
<br /> wilhin 30 days o lest date. -
<br /> A- Cellel•al Information �
<br /> Facilily Namc: —.ter _•••� ^/�'C✓' t,.
<br /> 1314 No.;
<br /> titlt:Address:
<br /> _�s /tel Jr� ........... ...--...c-'ily, _
<br /> )Z' lid/A1a ^ Zip;
<br /> I :,t:ilily('unh,ct 1'rr;,on: .. 5�, j,4 _ Contact Phone No.:(
<br /> ivlakc/Model ol'Monitorinl,System: --r(X Date of Te;tin,•/Scrvieio: �.ec
<br /> R. Inventory of Lquil)mcttt Tested/C'er(ified
<br /> f•herk like;Wlrrtrhriigr h(mrs Ito indieatt•n rrifir rt nipua•of lea,rel rd/,erl'iced:
<br /> Tk IU: r L:t
<br /> ---- '- �I
<br /> In=hulk('i:m)~tng I'ruht. Model: I n=1:ank(ien'ing Probe. mmlel!
<br /> AI mkir Space or Vault Sensor. Mudcl: _. 7,0 _ e P nnular Space or Valrll Sensor. Mudel:
<br /> Piping Sump/'I'rcnrh`jcnSur(s)_ Muriel: __._.. 1pinp,Sump/Trcnt•.h 5cfir :i . Model: --
<br /> U Dill Sump Si msor(s). Model: _ -- U j 111 Sump Srnsur(v)" Mndcl:
<br /> IdMeclumicil Line teak Detee,or. Model: jc�(J �r�N1ech;mictd Linc Leak Defector. Model: 402000
<br /> U f lectmnic Linc Leak Detector. Model- U Electronic Line Lurk Detector. Morlcl:
<br /> CJ Tunk Overlilt i I ligh-Level tietlsor Model: ❑ Tank Overfill/1-lit•h-l.cvcl tensor. Model: -
<br /> ❑ Other(specify cr ui nwn(ty)e tln(1 motel in Section L on Page'?), ❑ Other(s ritY equipment IYM and Illude)In.Sect ion E uu Pam 2)_
<br /> T. Ik ID:—_-- 'yank ID:
<br /> In-Tank Gauging I'mhc, Mtitlel: mL ❑ III-Tunk Ganging li'olle. Model:
<br /> Annular Space or Vnoll Sensor. Model.Af' 1 _ U Aorlidar~pace or Vaull Sensor. Modcf:
<br /> I'iPing Sump/'I'rcnt:h Sensor(~). Morlcl: A� 11 Piping Sump/Trench Sensnr(s). Mtxlla:
<br /> D FiIf Sump Scnsol-6). Model: _ 11 Fill Sump Sensol-W. Model:
<br /> 'Mcchmlic.11 Line Leak Detector. Model' 1;C16. ❑ Mechnnical Line Leak Detector. AAA
<br /> U Elcutruniv Line Leak Detector. Model: _ U Electronic Line Leak Detector. Modcl:
<br /> U'funk Overfill/1-filth-I..e.vel Sensor. MurJcl: Cl Tank Overfill/High-Level Sensor. Mintel:
<br /> ❑ Other(sccify a ni moot type and inimlel in Section E on Pa rc 2)_ ❑ Other(s,ecif•e u) Inept ty C and n(alel In Section E all Page 2).
<br /> - _ .
<br /> ))i, ►coRrr Dispenser ID:
<br /> U Dispt mita Cuntaoanenl Scil%rils)_ Model:....- U Dispenser Containment SCa50r'(s), Motlel:
<br /> —.._
<br /> $llCnr Valve(s) 'Shear VaIVC(5).
<br /> Dispenser Containment Float(s)and Chnin(s)• Dis leaser t-'ollrainment Floal(s)and Chaur(s),
<br /> Dispenser ID: �:' / Dimilmscr ID:
<br /> �U Dislxnser Coniuilllllcnl Sensnr(s). Mode):__,_—,_ O Dispenser C'onlaiunrrnl 5ensor(s). Mude1:
<br /> Shear Valve(s), A Shenr Vnlve(s)_ -- -
<br /> Dis xtnscr Containment Flont(s)and Chain(s). ,F7 Disrumser Containment hlont(s)and Chain(s).
<br /> Dispenser ID: _ Uispcnner fD:
<br /> U f)itilx:n5cr Collla)uurcnl Sensor(:). el: _ ❑ Dis Tenser C'unlaimnenl�Floa
<br /> Model:❑ SlluarValve(s). ❑ Shear Valve(s),
<br /> UDispcnscr Coniniliment Floats) lit('hahl(s) D Dis loser CUoluiuownt . and Chain(s),
<br /> — :,.
<br /> If the I:u:ilily rxuttaiu-1 more honks of-dispullwi;,rrupy this fonn. Inchlrle)nlimuulion for every(link and opdispenser nt the tacilily _•. ���
<br /> C. CertifiC:)tion - 1 certify Ihal the equipment identifird in Ihes dncotnw
<br /> ent as 'ensplectc 17`er•vv1red Pru accordance with the
<br /> manufachirers' guidelines_ Attached Ip Ibis Ccr(ification iv information (e.g, rmtnuGtcturm' checklists) nectmar3• to verify Ih;lt this
<br /> illfrlrmaliuu is correct and a rlul Plan showing 111e layout of monitoring equipment. For any equipment cap.'hie of gerlernling such
<br /> reports,I have also attarhrrf a copy of fire rellnri:(client•nlll6al app&): U System(Sc -u I/ Q Alarm history report
<br /> Technician Name(print): Signature:" -
<br /> S'71`rr a _ n � r
<br /> -u —
<br /> f'crlili<:,rtion No.; _ _ License.No.: `��
<br /> I est iqg Company Nnnic:_ f. t�.
<br /> _ /.l L C:i-." _ Phom No.:� i o 771`-1- 011Z
<br /> Z�y
<br /> Site Address: O ,�. G/ p��, � _ I tote(,f'f'cstin!�/ticrvicinC•: >' { �0�
<br /> I'a;c I of3 alnlf
<br /> Munilorin(l.Systema Ce-rt)ficatiun
<br /> �}'. i�(:i:tte(S fi8•r�:':ifeltl',r,/i rC:6\'lCtll';;
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