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Apr 15 05 11t26a -st (208&94-0 qL jA f forba,- 'Te,$t r (general lite Name: 11 /,;, , 111 / / / p.4 - Bldg. No.; .. Site Address _ �.� e ([ City: Ca/ Zip. Facility Contact Person: 'tft%7 Contact Phone No„ ?O MakctMWO or Monitoring System: LUPBF/ ✓ ,c. ,r Date of TcstinglServicing: B. Inventory of Equipment Tested/Certified Merit the aonrenriate btu w to Indteate sueelfiLm nuftmemit N Tank ID; ,ier1 cf. Q -tri -'Dank Gauging Probe. U-Knnular Spam or Vault Sensor, Uffiping Sump / Trench Sensor(s), U Fill Soup Scusor(s). Q'�iechanic Une I,,eak Detector. ❑ fileutrtmic Linc Leak Detector. U Tank Overfill / lligh-Level Sensor Model: _ Model: a c Madel. j Modek MCKW. Irl/ Model: Modell iodel in Section E on Paft 2). Tank ID: U In -Tank Gauging Probe. Model: ❑ Annular Spat= or Vault Sensor. Mold, ❑ Piping Sump / Trench Scnsor(s), Mtxlcl;. LI 1411 Sump Sensor(s). Model: ❑ Mechanical lane Uak Detector. Model: ❑ Electronic Line Leak Detector. Madel;'— * 'rank Overfill/ High -Level Sensor. Model% ❑ Other (specify otluipment type and model in: Section Ct on Pae, 2). DisK-Wr 1'111: / &' -D— Cl Cl Dispenser Containment Sensor(s), Model: ❑ Shear Valve(s). ❑ Disnenser Containment Roots) and Cliainh Dispenser Il); ❑ Dispenser Quitaitnttent Sensor(s). ❑ Shear Valve(s), U DisMn4cr Containment Float(s) and Model; Dispenser 10: U Dispenser Containment Sensor(s). Model: ❑ Shear Valvo(s). ❑Dispenser Ctmuuntnent Roat(s) and C:hain(s facility c (nitains more tanks or disponsen, copy this; Tank W! _ 54/01 — I MM&ik Gauging Probe. Model: ❑-Annular Space or Vault Sensor. Model: U -Aping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sent,rn(s), Madol; GFIM—hunical tine Leak Detector. Model: C 34 / V U Electronic T inc leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model; ❑ Other (.�xifv eouirunent euro, and rnadel in Section E on Pace 2). Tank ID: �✓ / U -5 --Tank Gauging Probe. ❑ Annular Space or Vault Sensor. 01rip--ing Sump / Trench Scnsor(s), U IN.Sump Sensor(s). WMcchanical Linc, Lcak Detector. ❑ Electronic Lint: Leak Detector. U Tank Overfill / High -Level Sensor. ❑ Other (soc ify muipment type and r IU 11,, Model• T/ /--sem Model:'— Modd:,/=-X117!/ _ Model; Model: _. thiol in Section Ir im Parte 21 ❑ Dispenser Containment Sensor(s), Madel: ❑ Sherr Valve(s). 4 Disp,rtsor Containment Rnot(s) and Chaint DibVomser 11)• ❑ Dispenser Containment Sensoils), Q Shear Valvc(s), ❑ Dispenser C'.cmminment Float(s) and Memel; Dispenser ID: U Dispenser Contai-tunent Sonsor(s), Model; 0 Shur Valvc(s). ❑ Disnenser C antaimnent Fload-1 and C_hain(N)_ ittfomation for every tank and dispenser at tlw C, CertifitatiOn - i errtity that the cq identified in this document was inspect-1/sarviced in accords om with the manufacturers. guidclire& ,Attached to this Certification is information (e.g. rnanu checklists) meCa't ry to verify that this inforination is correct and a Plat Plan allowing the laic ut of tsauitoring equipment. For any equipment tapable of 10Ch attached n c of the r gcrluerattng rt�nrts, i have also copy report; (cheek dAA&4pply): O System stet -up ❑ Alarm h6lory report Technician Namc (print): ,1 ,( JU, tst9 pw, ,� Signatwa: _ i, Certification No.;. _ Q'4 a (P 3-6 "/� License. No.; �. g" 1 ATG Monitor Form Monitoring System Certification -