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K; 24-2005 11:44 FROM: TRACY T�CK & AUTO S 12098325307 � 4683433 P.1 <br />),13 <br />For L'se 5v.411.1unsdic:ium Within the Stare o(C.'aiiiornia <br />-4 urhorify Cited: Chapter 6.7, Health and Safety Code: Chapter Ib, Division a, 11t/e 23, Cali1brnia Code c�r'Rebulartans <br />This form must be ased o document u and .smv=ng of mmuituring equipment k senarnte c.-rtification or retort must be <br />prepared `isr each moaitrt Mg system contrat hone! by the =bnwm who pe.:W ms the wars a copv of [his twm mun be provided <br />w the tank. system owneriope=r. The oevcter/opemtor mmst sub= x copy of this form to the iccai agent m—ga lung LIST systems <br />wiihm 30 days of test dale. <br />A. General Information <br />>:aedity Name.. 7—r uC A. Y?' -y SmTic-. Station No.. <br />Site Address: ? ` ' Y © I iIi �4 C rr [711,41 City: Tri <br />Fam1hy Cautna Pcww Cow. -=t Phone No.: <br />MIta&1odel of14onsuring System: Date of Tung/ - lU� <br />B. Inventory of F. p#umeant `fGitt Walffled <br />Chi the ;moronrsaate bataaea io mdkitc die cuff v=19t iOa�ee>ped%d: <br />T ID:7 <br />T ID: clZ <br />Gangue Pmbc. Model: pigk r - [ <br />ode <br />'Tank Gauging Probe: Mr: <br />Space or Vault =WModel: A�,o keo <br />�,% <br />ILS Spact or Vault Sensor Mode: <br />St1,lIIpTxem* Sensor (s): Model: go <br />m$ Suutp/irettc3i SWrdVi {S}: Model.u L:csc�; c <br />Sump Seusur (s): Model: <br />scm4wr (s): twlode.:: <br />04echavical Line L=k Dou:ctur_ Modei: a:eeuLa <br />lRaechani=1 Line Leah Detector. ibfods': S7r <br />CHRettamnc Line L=k Dir Mode.': <br />C ROccwnfic Line Leak Detector Madel: <br />!]'Tank 0vcrG1 iiigh4cwJ Sensor: Mode:: <br />OTankNesfll/Higit level Sensor: Model: <br />C34tb--- S2EEk =nip, and mold in Section E on PW 2 <br />00d=: Svecifv =um, type and model in Section E an. ,!" 2 <br />T ID: 17 , e S e t_ iJ , 7- <br />Tonic ID: ca 'T-' , <br />�n-Tank Gauging 3'irtite: Model: p^� � <br />Qin- dank Gauging Probe: ►Ylodei: <br />04zwSpam or Vault Sea . Mode -L. 62C ri ti avvi, <br />606nlar Space cx V=& Sensor ,Vfade3: ✓/ Xf-till Voe, <br />Sump/ reach Sensor (s): Model Az—ale—ow.—O <br />Cpiiug Sump/.'xeuc$ Senor (s): Mode.: 00.4 0 2ST—or-o 7a <br />CFP Swasg Sensor (s): Model: <br />OFRI Sump Settsar (s): ModeL <br />Line Leak Detector. Model: i?!j t j2 Zv n <br />[3hkclramcti Ione Leak DEte=. Nlociel: <br />tic Lame L=k Deter Mei: <br />CBEkctnDnic Line Leak Dcic=r Mudd: <br />=auk Ovesfl 1Higj evei 5emor. Mcdch <br />GTank 0vcrfiW iglt-,level Sensor. WAdd: <br />00dw, Stteafv cqmp type and model in Sect=E on Page 2 <br />00d=, Specify emm. and utodel in Se^:imE on PW 2 <br />ID. t—.7— <br />Dispenser ID: 9.= Le <br />Cantamineut Sensors: Model: <br />[N)iSpens+er Containumid Seuson(s): Modet: <br />M -1h= Valve(s). <br />Valve(s). <br />Vit <br />Com' Containment Float(s) mad Chain(s) <br />ser Cout2xnmem Fbnt(s) and Cbuin#s) <br />Digoner lD: C. 6 <br />Dispenser ED: 7 9' <br />ODispenser Canwinmud Sensors: Model: <br />CIDismser Containntent 5eusar(s): MDdcl: <br />i Shear Vaive(s). <br />Qtuw `Vaive.{s). <br />C Fioatt:s) and Chain(s) <br />C isvetrse: Com Flaat(s) and Chain(s) <br />Dispenser ID: - i a <br />Dispcuser ID: { VW09 '. o3 <br />Cantaium Sensmr. Model:C�ix�ent <br />$bear Valve(s). <br />Settsrnr(s}: Madel, <br />=Valve (s). <br />26isttenser Comainaurnt Floatfs) and Chaia(s) <br />Containment Flows) and Cbain(s) -_ <br />*If the faez]ity comains more tam`s or dispeusets, ccpv this loan. Inch de information for -MV tank and dispenser at this faciWv, <br />C. Cer'tifiC2tion - I certify that the asluipmeat idendfmd in this document -was inspacmWservima in a=ordsare with the <br />mftufacmmm' guidefve& A#ached to this Certification is :nbrmxuoa (e.g, mauufacmram' checklists) necessary of verify thug :his <br />wfurmadan is correct and a ;'tot Plan ihowing the layout of mounaring eanipm,�emt. For any eynipum"punle of aua; enerseiJuga <br />�g�zrts d Save also attached .& wpy of the report; lctirrlc amtiar,rfrpiy), ,..__systemset-u+p istory rEf4rT <br />Tecbnwian Marne (P / <br />aint): �'r✓(' S"7`r� nl Signantre: L, �^j " <br />C-Irnf=tion No.. j (L License No.: <br />. esung Company Name: Cbamition ?ze stou i esany lac ?scone No.. t 9 Ci i 42 -:5� <br />'.JAan ar 3 +001 <br />