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Facility Contact Person: ,Make/Model of Monitoring System: 0-M tj 7Ec— City: 5=0 ®t.z Zip: 9 _ Contact Phone No.: `7 ) - Q 6S� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes,to.indicate speciric a ui ment ins ected/serviced: T e ---T Tank ID: Jp-Tank Gauging Probe. Model: 13 In -Tank Gauging Probe. Model: J nular Space or Vault Sensor. Model: 6CA&4 Piping _ ❑ Annular Space or Vault Sensor. Model: Sump / Trench Sensor(s). Model: LS . El Piping Sump /Trench Sensor(s). Model: 1U3Fj l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: .P"Mechanicai Line Leak Detector. Model: Fpc- 1 ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (speciuiEment tyEe and model in Section E on PaLe 2). ❑ Other (specify equipment a and model in Section E on Pae 2). T ® e --T' Tank ID: In -Tank Gauging Probe. Model: A161 ❑icnnular Space or Vault Sensor. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ,3 Piping Sump / Trench Sensor(s). Model: t a _ ❑ Piping Sump / Trench Sensor(s). Model - 13 �xil1 Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: )j Mechanical Line Leak Detector. Model: J::X = ( ❑ Mechanical Line Leak Detector. Model: ` ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: -and ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment a model in Section E on Page 2). ❑ Other (s ecia ui ment a and model in S tion E on Page 2). Dispenser ID: ' "�- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑Dis user Containment Float(s) and Chain(s). Dispenser ID: °I- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ DiSEMser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copyOUs 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 Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring '' 'pment: For any a ment capable of generating such reports, I have also attached a copy of the report; (check aft that apply): System set-up Alarm history report Technician Name (print): (P � ) �s4nl�- ! ` �ra2�'% Signature: Certification No.: /� ��5 License. No.: # •%j"Z - UT 077L V! 04 lt��► Monitoring System Certification