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t <br /> Work Order: 2255571 <br /> A,-'!')N6T.f31 Iii o S.'ST P•,1. '1+.11TIFICATlt)'. <br /> I rrr t?ahp.Ul.;�riv!�{,i�u.rFf'iliri:r e7r.lr,rra,,:<"�Jir4r r .t <br /> terhln-rrr1';rrre:f'l..:ej�.v B.:lrrtrlrl:rral.Yrr i•: rl'•..:Chq ra•i'Irl,1.,...o,.v J.,;.{'3-L'a?i%w'.•rtut'rh:i• <br /> i <br /> Thls firm itust be mcd to ducurncnt testi.rg:nnl servicing of monhotiug cgi-.iprncnt. A cel>2nfr_ce.of irxt CilTpat mid hr. <br /> rn err-r_vd fnrler_Ip.r�tnnityyi} ycttni cuntrcE grinS{by the teeknic oo who p:rf!nrErs tErc was k. A copy orthis frrm neox be Fuovidrj w <br /> the tank syslcm ownerrtyxratur. The ewtledaperator must suhmir a copy of this farm to the Iccal agemy rc, dating tiSi'syskrns <br /> within 30 da�s orzesi dat " <br /> A. Geticr d I 11tinnff / <br /> FaciliryNatric:_ � � � r t17/ —'— <br /> site.Addressif�.3 /t:-_. Y.rr City: 7twKTon( _ -Zip:�gZn�. <br /> kacility Catt$iil Person: - _-• Contac[Phone Ain.:( �U�FZLYUY_ <br /> a\Aakcrhiodel of INniilttring System: Dote of-festinourvicing <br /> B. IDevcnthry of iegtlipment'reste(VCertified <br /> (,'r.r.'k dKa �@IekWlY p11M1lraSL l®rK 1lRt inti,aeiedLePrviecd: <br /> Tank Icer: 4 j oG-7 Tank ID: <br /> A In•Tmdi Csiaoi,m I'M-, MUCK 14A ittit In-Tank Gaugala Etre. MO&II: MR6at _ <br /> �Annular SR:meorVault seaw. MOM: 407 14 AnnularSpoo-VaukSananr mexk>I: <br /> ¢L Piping Surtgt(Trcnch Seuvats). MaaY_I: A Piping Sunip 1Trench tiae:nrs} � <br /> Model: <br /> $fill Sump Sknsa{s). Modcl: _....Z X Fill Sump Serra*3L Mu&l--. <br /> ne <br /> CIMeclumiailif—kD,-incl - Model: ❑MechanioalLine I&A N.tecror. Mudef: <br /> 19-Fleamic Darr Leak Detector. Madel: AIL Ekuutsnic Une?x*Detev:mr. Mudd: (,LD <br /> O Tunk Ovcrfl"11140-Level Srn r. Model O Tank Overfill/I Gbfi-LordeL- <br /> d Sensor.Mu <br /> O Other 1 c:f n u type--d motel in Model:­ <br /> Ii on Pape 2). U Other(s cifvp ui nent type and model in SLciion E an <br /> Teak ID: Tank ID: <br /> O Ir wTank Gate-ging Probe. Model.-..—.. - 4 In-Tatlk Gouging Frobe. <br /> gAmurlrSpace or Vault Sawtr. Mtxtel: J(tAnnular Sim.orVault Snemr. Mute):_ —�F- <br /> (3 Piping Suav i Trench Sft'aur L h9tidel: U.Piping Sump l Trench Seusav[s). Maki:__ _+x.52 <br /> P FIISaotpseraorls). Model. OLFBISwnplrnsnr(a} M.M. 9LrX� <br /> U Mm .•mirnll.aK Trak Dalei.:rur. Model: •_ a Meduxriepl l3lx l.enk lkircr� Model <br /> 0Eleedtml-16-f�-&Detecar. Mad{d: ___ 4ElectrenricLine 1=*Detector. ModeL_ _ <br /> Q Tank Ovreffll I High-Level Seiaor. Model: Cl Took Overfill!Rgh-Level Sensor.Witt: ' <br /> El Other( 'F ei m ty x and mt�cl in SectEnn k on Y e Z. []Otke fv i mm type and m.-Kiet it,Section E an Pa 2). <br /> Uispcns�aD: /�L Dispenser ID: 7-018 <br /> 12fAspnoerCoutaum,a,tScruatsL Mnrtel:_ O6 ®.DispenserContoim,mdSeuiagls). ModcL ZOIet <br /> A Shear valve('}. — p!kqhcar valve(,). <br /> O DL'carr Comaitmem Fkxatm and LYeim(a). Cl D ser Ca,toinmott 1`10,1109)and Chui„(s). <br /> Di penaer lD:. Dlspeowr ID: O <br /> ID Dispenser C*9A m lt-%mv(a). Model: 9A8 Dispenacr C'ordainment Senmr(s}. Menkl:— 2108 <br /> fd.Shtan V'itiv4). 9 Show Val-(a}. <br /> O Di C itainm;nt F1oago)and Minis). O Dia user Cadain lent Floats)and C'ha}a(A <br /> Dtapenwr 11): i IN pemer ID: // ¢•le j! <br /> Fl DEsp,asa C intainaxm Scn mem( . mm";_ ..1 ._ Ed Dispntser Cr,nMEnper,d Semn,Oa). M,ukl:_ _ <br /> RK Shear Vatic($}, A Shcv Valve(,), <br /> 00ispenscrCoritaiwKnt Flash')mui Chainis). I DJ Dispeoru,,Cemtalumm Fkm4s)and Chaints). <br /> •I Cthe fxikty ctintane nttae tanks nr 3isprrt�le•ayi;•thi<fait hwfiale information rw•evey took a td dispaw at the faeifity, <br /> C. Certitiicatlon -f certify that the egaipment IdestirKd in dih docummit has imfmmftdi'servieed hi se"rih—c with the <br /> prannfacA}rrs'gr®ilrtiatY. Attached to IkEs CertifiQtMn is krfanwalina(C,¢monabecumrs'eheckuxly)nmcssaty to verify that this <br /> infermathip b correct and a Phot Plan showing the layout of nrunAuriq,etlaipouent For onv egn40-9 mp.me of P.r—piing.—h <br /> reporis,I here am atfaehed a Lopy opf�the report:(rltech alt Thal mWy): ASystr -s no history report <br /> TeeltnicianName,(I�K Za.J� . �q„� Sigmhs'c:_ <br /> Ceitificafim NO.:_....// � License.Nn•: C 5 33 7ry[+U%' <br /> Tes[higC'ompar}'/deme:. 1,lFmmT _PhenalVa.:U01 <br /> She Address: ✓ ._ _D:deofTrsiing'S^_rviciag; J B j e>g <br /> Pace 1 of) <br /> htonlft ring System t:erfifiration <br /> D. Resn)tslifTestindses-vicine <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />