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ry N ItI d orb -�Fp - ctjGb 'QUALITY TESTING OF UNDERGROUND 7AN)UAT A FFORDAB rs<,4�EN 1 HEALTH H a 416 2nd Street Galt, CA 95632 (209) 744-0112 F r`l�44R� d GeneralInfor"atio , ! Facility Name: A ) u c � ,/�ao�7 I { Bldg.N o.: SeAddess: City: � Zip: Facility Contact Person: VYIW"I a -1 Contact Phone No.: (_Z() Make/Model of Monitoring System: h k- Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate peciflc a ui ment inspected/serviced. Tank ID: j� V l �__ Tank ID: L r ❑ In-Tank Gauging Probe. Model: 4 dDLA: ( ❑ In-Tank Gauging—Probe. Model: 40'7" i--�,� , ❑ Annular Space or Vault Sensor. Model: ' — ❑ Annular Space or Vault Sensor. Model: '�Ul4��'ta Cl Piping Sump/Trench Sensor(s). Model l °5r7 a�Ca ❑ Piping Sump/Trench Sensor(s). Model: Fc ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(Specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Cl Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s e ' Equipment gpe and model in Section E on Pae 2). ❑ Other(s ecia ui ment type and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: =r ?' ❑ Dispenser Containment Sensor(s). Model: Q Cl 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: ❑ Dispenser Containment Sensor(s). Model: E) 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser 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. AtL-tched to this'C1 ertification is information (e.g. manufacturers' checklists) necessary to verify that this information is -correct and a Plot Plan showing the layout of monitoring equipment: For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history re ort Technician Name(print): Lt J)P i V � yn n Signature: Certification No.: e' y;" License.No.: (��Ti — Gjt') — t CC = 52.LA9 1 15 w LO 1✓Tnni�nrinrr�-'r�rinm ('�rfi�n•.�finn '