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Site Address: �� '+'�� `'E 4_AW - City: Z-Z,>A e Zip: b Facility Contact Person: 1 DA 12- Contact Phone No.:( 2-6q N615- ?8C, ( Make/Modei of Monitoring System: YE8Df12 Rb07 Date of Testing/Servicing: B. Inventory of lEquipment Tested/Certified Check the annronriate boxes to indicate specific equipment inspected/serviced: Tank ID: L-'!`,7 G C.. 7z Tank ID: ❑ 1prTank Gauging Probe. "Ranular Model: ❑ In -Tank Gauging Probe. Model: Space or Vault Sensor. Model: g o .f�nular Space or Vault Sensor. Model: _ Za Piping Sump / Trench Sensor(s). Model: Piping Sump /Trench Sensor(s). Model: ❑,FiH Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ' Mechanical Line Leak Detector. Model: ST P M t -h p'wlechanical Line Leak Detector. Model: X. L.. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Page 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Tank ID: It ( G C..' -r Tank ID: ❑�Ip-Tank Gauging Probe. Model: C1In-Tank Gauging Probe. Model: .0nular Space or Vault Sensor. Model: k4f— I-AM4-❑�P anular Space or Vault Sensor. Model: ;niping Sump /Trench Sensor(s). Model: �� �I Piping Sump /Trench Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: 151 P - Lp ❑ Fill Sump Sensor(s). . Model: ; echanical Line Leak Detector. Model: M Ja Mechanical Line'Leak Detector. Model: FX.- Z. t> ❑ Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui inent a and model in Section Pa e 2). [� Other (specify a iii ment a and model in Section E on Paa 2). 'f'- -2—Eon Dispenser ID: I - Dispenser ID: ? �- ❑ �?ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ' 1.0"bispenser Containment Float(s) and Chain(s). -E3'-Shear Valve(s). ,fd'Dis enser Containment Float(s) and Chain(s). Dispenser ID: 3+'( Dispenser ID: 4 / Q ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: .O Sbear Valve(s). 21`7 hear Valve(s). .❑ Dts enser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 'f Dispenser ID: i---1 T AE ❑ j)ispenser Containment Sensor(s). Model: ❑ ]dispenser Containment Sensor(s). Model: Shear Valve(s). 1,26spenser Shear Valve(s). Containment Float(s) and Chain(s). A Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Gerdflcafion is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring egtent For any equipment capable of generating, s eh reports, I have also attached a copy of the report; (check all that apply): -, Y, stem set-up ElAlarm histary report Technician Name (print): Z�/�!� Al i rnnSignature: M . Certification No.: �� License. No.: �'[�� .�Z(� � 3 2,9 UT 077L 14 Monitoring System Certification