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racrirty rvalrtc:tri vv r p�snr9V W-, t s L_> C bldg. No.: Site Address: _Li'/ Q 1- , t- '� x� �-a Qt r/ L City: J 6Ck� Al Zip: Facility Contact Person: - W_/ L,'h Contact Phone No.: a /-/& " Make/Model of Monitoring System: L, -,'-i`[4 "ter°9' Date of Testing/Servicing: 3 B. Inventory of Equipment Tested/Certified Check the anuronriate boxes to indicate specific eauinment insnect Tank ID: - /W -[l f-- _ Tank ID: _ t % ❑ In -Tank Gauging Probe. Model: Y1 > Qi a ❑ In -Tank Gauging Probe. Model: �j ' ❑ Annular Space or Vault Sensor. Model: � �0 ❑ Annular Space or Vault Sensor. Model: b�� °' 01•41.Vr�) It ❑ Piping Sump / Trench Sensor(s). Model # ," ❑ Piping Sump / Trench Sensor(s). Model: ❑ Frump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: B -Mechanical Line Leak Detector. Model: "7T -/31.X-,t7 E Mechanical Line Leak Detector. Model: 9'+ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment ty2e and model in Section E on Page 2). ❑ Other (s eci ui ment tyRe and model in Section E on Pae 2). Tank ID: Tank ID: / il?" 0 ❑ In -Tank Gauging Probe. Model: 01—n -Tank Gauging Probe. Model: (a? A ❑ Annular Space or Vault Sensor. Model: Cfi Annular Space or Vault Sensor. Model: ,/, e t ❑ Piping Sump / Trench Sensor(s). Model: a°>s ping Sump / Trench Sensor(s). Model: i0AP -PL , i D ❑ Fill Sump Sensor(s). Model: ❑ FjjLSump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: echanical Line Leak Detector. Model: -JO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specifZ a ui ment a and model in Section E on Page 2). ❑ Other (s eci a ui ment a and model in Section E on Pa a 2). Dispenser ID: / Dispenser ID: 7 /_/ ElDispenser Containment Sensor(s). Model: W ' ❑ Dispenser Containment Sensor(s). Model:gO ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 6 — Dispenser ID: J ❑ Dispenser Containment Sensor(s). Model: d'� ' d� 3 ❑ Dispenser Containment Sensor(s). Model: n POS" ® ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Hoat(s) and Chain(s). ❑ Dispenser 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). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this 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 ofmonitoring equipment. For any equipment capable of generating such reports, I have also attached of copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Signature: D C' t -- Certification No.: License. No.: , APR 0 5 2004 Page 1 of 3 ENViRONMENi HEALTH 03/01 Monitoring System Certification PFR�JIT/SFRVIU-S