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l� iELL QTI3 COMPA_�?v-� :IFICATIOU OF UI;DEItGROU.._ <br /> F`a•bility WIC Number : 70`1 "7JZJ ' olocf <br /> Divtrict : OF <br /> Facility Address <br /> Purpose of Visit <br /> Tank/Line Material ( ] Steel <br /> [�] Fiberglass <br /> Product Tanks Single Wall <br /> Product Lines [ ] Single Wall [3) Double Wall <br /> [3 ] Double Wall <br /> Waste Oil Tank <br /> [ ] Single Wall [ ] Double Wall one <br /> roduct Tank Monitorincr pyatem <br /> QTY TYPE <br /> [31 Interstitial Monitor (,.�) Wet [ ] Dry <br /> [ 1 Vadose Zone Monitor <br /> [ ] Monitored Visually ( Daily Inventory) <br /> Manufacturer: API Reservoir <br /> [ ] [ ] Genelco [ ] API Ilt (VAUOSE) <br /> API MOS (VADOSE) <br /> [ ] OC [ ] Pollualert ( ] Leakalert• <br /> Soil Sentry <br /> [ ] [ ] Red Jacket <br /> [ ) Spearhead �- ] Uthe� h��F,„ �• <> <br /> ode or eta �LVC� <br /> Status @ Arrival : _[>< , Operational <br /> [ ] 11011-operational,Corrective Action:acture: ( ] Performed [ ] Required <br /> Status @ Departure: S>4 Operational [ ) tion-operational <br /> off a <br /> roduct Line �ioni ring lays tem <br />. . QTY TYPE 0/o <br /> [3] Electronic Line Pressure Monitor w/nfiechanical Leak Detector <br /> [ ] Interstitial Monitor w/ Mechanical Leak Detector <br /> [ ] Mechanical Leak Detector Alone <br /> Electronic Line Pressure or Interstitial !•fonitor Manufacturer: <br /> [ ] APT Pressure [ )-A-P-1 Sump (><j, API Sura Line <br /> [ J Leakalert ( ) Other _ P/ <br /> LS- 1 �J <br /> Status Q Arrival : [X] Operational [ ]/ Non-operational <br /> Corrective Action : [ ] Performed <br /> Status Q Departure: [�] Operationafloe- <br /> l [ ] Required <br /> [ ] tlorroperational <br />