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'�-7' v 'E� vtECEWED Ac", S T E M C E F'-" i f,16 2008 ONITOP'Xita 20 AuthorilY Ciloil., ('haplcr h.7, Iletillh ('orlc; (Atip1cr /0, Divi.%'ion 3, Til/ti,�MSWNT REALTRIth ah nis nce This form Must be used to dOCUrrient testing and servicing of monitoring equipment. A R5ANTIMANNUor report n1USt be prepared for each monitoring,system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator 111USt Submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information 'r,ed SO-66 015"�h Bldg.No.: Facility Name: S"aK"_ yi �o, ) Site Address: ) UI-6-.?-- � I P/ ),I )t City: zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Zeoe ki_ � /00 0"E _,z Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecilic equipment inspected/serviced: Ta D: Tank ID:ER" -17 in Model: n-Tank Gauging Probe. Model: -Tank Gauging Probe. Aj�inylar Space or Vault Sensor. Model: SSP LS Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: u 15 aq Piping Sump/Trench Sensor Model: L3 FD.Sump Sensor(s). Model: El Fill Sump Sensor(s), Model: R-Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: C3 Tank Overfill/High-Level Sensor. Model: 0 Tank-Overfill If High-Level Sensor. Model: U Other(specify eqUilInlent type and model in Section E on Page 2). 0 Other(SpeciL=k=2UUe and model in Section E on Page 2). _T7,_.k ID: Tank ID: C3 In-Tank Gauging Probe. Model: L3 In-Tank Gauging Probe. Model: C3 Annular Space or Vault Sensor. Model: LJ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: EJ Fill Sump Sensor(s). Model: E3 Fill Sump Sensor(s). Model: Ll Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: U Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: U Tank-Overfill/High-Level Sensor. Model: 13 Tank-Overfill/High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Page 2). J Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser-ID: El Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). C3 Shear Valve(s). L3 Dispenser Containment Float(s)and Chain(s). LI Dispenser Containment Float(s)and Chain(s). Dispenser ID: L( Dispenser-ID: J Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: LJ Shear Valve(s). 0 Shear Valve(s). U Dispenser Containment Floats)and Chain(s). U Dispenser Containment Float(s)and Chain(s). Dispenser ID: b Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: LJ Shear Valve(s). El Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). *11'the facility contains more tanks or dispensers,copy this form. Include information for every tan%and dispenser at the facill,ty. 5 ef- 4r/0 -( -&/—. � 1 k' in accordance with the C. Certification - I certify that the equipment identified in this document U)was tiiispeeted/se-;�,coed' " manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attach d copy of the report;(check afi that apply): ET Sy Alarm histo rt co' Tpet-UD repo (print): a _0 U Technician Name(p )_ A D. Signature: Certification No.: n1' License.No.: 0 90 -I M37 Testing Company Name: 70E 517 Phone No.:(,2AOq 0 1 a2 Site Address: Date of Testing/Servicing: III Page I A 03101 Monitoring System Certification D. Results of Testing/Servicing