|
Jan-03-02 02 :03P CHAr% ON TANK TESTING 916 27 7345 P.02
<br /> MOMTORING SYSTENNI CERTIFICATION
<br /> Fov Use BY,-!II Jierisdictions It.IrIzin 117' Ulf Ccllf'iUvnta
<br /> and Sakfy CO(Ye.- Chal)(er 3, Tm,"'i3 CUgh,of
<br /> Tli:s Form niii- lw. Mod lu doctinw-nT testing and servi4inrr r
<br /> of rzionitorbi: -,quipriicnt. Sepap:-z cinf
<br /> M I _.- .- fiCAtiU_aL_r_uPrt_niust b..-
<br /> prt.marcd fOr egjj ritonitorin.v_vstc-n wri!go)j2ap�.l by thet '
<br /> WhIliCiarl who per."orni,;th-1 woik. A cn: o:this fivill 111LIS,be pruvidc'd to
<br /> ti'-.- Milk owne.'upmamr, o rot 111LISE subnii-z i cep} o'tl:s forill to the I
<br /> v.iTIi1;i 31)kkiv-:of'LoOda!"
<br /> A. Get ei-al Information
<br /> I'acill-N Narnc: —Slrx la-J-6__LZ IZ2
<br /> BIjin, INO.:
<br /> Site Address:
<br /> lot 1-1A1_A1., 429 Zip:
<br /> Facility Contact Person: f /111.- '111
<br /> Cnwict Plhonc No.
<br /> Make'.Model of*.Morii Lorino 7tJ-- I.4100 Datc u1'Te:-::,2 Sen-ici
<br /> B. Inventon' of Equipment Tested/Certified
<br /> Chtd%the.apprapriate hOKCS in indicate s ?Viric 0�tziErnent insp
<br /> ected"serviefid:
<br /> Tu k I D iA V7 4 Tank ID,
<br /> -'Lank(lati-eing Prcilw. M'o j z': 17rijiging ProLe.
<br /> k .. .... Model:
<br /> Space or
<br /> Modzi: ""I, Space ur Paul:Sens': Modc..
<br /> 'ula. PA _r
<br /> Trench Sc
<br /> Sump in "iping S'-.1 Inpi 1'rench Senson s
<br /> .�c ", lisc.,s I. %lodeL U
<br /> U HI Sump Stm.,ur(�). Mod:t: IJ Fill Surly Scrsor(s)
<br /> FriMechanica[Line Dctcmr Mcde!'. ililli2chanic�31 Line Leak Dctcc�ot "10M. FT I
<br /> 0 Elccrronic 1-inc I.cak DcEecror. Model.
<br /> _J E!ccrronic Lind Leak \10jel:
<br /> 0 Tank Ovcrfifi.;Hivh-Level Szn_ur Model: :;J Tank 0\crFI1,'High-Level Sensor. Model:
<br /> Zi Other('specify equip-nienr tl tie and in Sectiur, on Parc 21.
<br /> C3 Oihc-. (specify equi2r-,icrl typ 2.,d""Jel in Section E on PRzC 2),
<br /> Tank ID. Twih- ID!
<br /> .:I IrJarlk,Ciauvir._�Pruhe. MoJCI: Q In-Tank Gauging Probe.
<br /> j:- L3 Annular Space or VIMIZ SC1730. Mode!: 0 Annular Space or Vault Sensor. Model;
<br /> I LJ Piping SUITIP I"1'rench 1. " 0 Piping 15,jMP/Trench SensorU! %lode!.
<br /> Fill Stimp Scrisor(s). \10 d U Fill Sump Sen5or(s) Mod-.1.
<br /> ❑ Mchaiiic3l Line I.cak Dctm;:or. 1%'oA:l; 0 Ivitc1hanizal Line Leak Detector Model:
<br /> 0 Uocironic Lirx Leak Dctccc.-. N 10 d L-1. U Electronic Lime F,e;jk Nrcctor.
<br /> H;'oh-Level St-ns'or Nlodc:!- 0 I'ank Ov - ' Mode::
<br /> Z '1'3:ik O� crffll/High�.e% Njocici:
<br /> D Otlhr(specify equipmefit t+ve and mc&l in SectionE-a-r-PaQc:1). :3 Other(saecif-. equirimmi: typc ant model in See:ion 1:on Pagc 2)
<br /> Dr enser ID: Dispenser ID:.
<br /> rb"sPenst7 Containment Scriso.- 1,vici
<br /> CJ Shear Valvcfs) L:J Shcar%'a!vc(s).
<br /> Do',periser C0r1t2i11T11C11'. Flu;Lh,1 arl,f 0 Floatis,
<br /> Ij il L e-4,dowl Dispenser ID.
<br /> ?ipenser ID. .7
<br /> YM.�jxnscr Conlain-mcni Scris.i-;Ii) M""-!�
<br /> Z. 0 Disperier Containment Scriso-
<br /> 1:J Shear Valvc(s), 0 Shcar\'olvefs).
<br /> Z2 Di-muriser Con:.!inmem C*.-.:i;7-j Cot;lainmer,t Roav s Z:h airis).
<br /> Dispenser ID: Dispenser ID.
<br /> 0 Dispenser Co,-,t;tin--r.cnScis,x,5) Mod-,!: 0 DispenSe7 Coniai-irre-it Sensori Mode!:
<br /> J Siwar Valve('). 0 Shear Vzlvc(s).
<br /> :)!)isnun�::r Corr;,.'nmer: Float(---i and ZJ D!snenser Canmnrnen!P10:1115,
<br /> I IC me t'acilltv can,1!:i:;mcw^ian�.N ot cop\ ih:i fovm. Include!nforn-nition for every an',-and disp.-n. at:he *a,-,I lits.
<br /> Cel-tifiCitioll - I certify cluit the v(piipment identified in this document %Fas in accordance with the
<br /> rnjnut*acturers* auldellne%. Attached to this Certtflention Is Inrorniation (e.g. rriantifactiii-ers' cher>,!ists) necessary to verift- that this
<br /> informution is correct and a P101 ?,an shmNing the layout of monitoring ccluiprincrit. For an}' eclizi.prient capably of generating such
<br /> reports, I hnve also11 1 1tichv_qu vop% of the report. (check all rhatapp,�,)! System t up Z_ILI-rm history report
<br /> .* -
<br /> Tc h:tiriarlNaine i Print). Sianawe:
<br /> 'cens,
<br /> C')nloanv M:nc --9'-71W10j1.! �N_k T�S�iJ9 Plion, No.:( VVY
<br /> _J� ) dx6_Q �r _
<br /> '.70 59 SSC,, ,--A 9.r- e'? -SOS c? uxe S,:rv:cin.
<br /> PI-le I at 03101
<br /> Monitoring Cerliflicatifirl
<br /> I). pe�tif(s u1"Testill g/S el-N f cilia
<br />
|