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hi .m1 @ 54 t t 1J o EYED !_ AUG 0 8 2006 'QUALITY TESTING OF UNDERGRO(IND 74NKSAT )RDABLERATES' � /�RONMENT HEALTH Post Office Box 36 Thornton, Ca 95686 (209) 5J4Jk1 794-0112 General In forma tion Facility Name: EL aksrc12 Bldg.No.:_ Site Address: 1533 COLD1JY 12-D City: 46fj Zip: 53 Facility Contact Person: S NA141: Contact Phone No.: ( —Ia�l ) 5tl - 071- Make/Model of Monitoring System: eEDIEW— l CSJ-36a Date of Testing/Servicing: 2pt —I—L(--% B. Inventory of Equipment Tested/Certified Check the a2propriate boxes to indicatespecific a ui ment ins ected/serviced: Ta lc ID: l EE-L —r- I TT4ak ID: co C---r —C-1 ank Gauging Probe. Model:'111MACIt -Tank Gauging Probe. Model: MA!61 1�1 �ernular Space or Vault Sensor. Model: Ci*nular Space or Vault Sensor. Model:_ ing Sump/Trench Sensor(s). Model: AU ing Sump/Trench Sensor(s). Model:_�8 e F'1 Sump Sensor(s). Model: Sump Sensor(s). Model: �gMechanical Line Leak Detector. Model:_ ffPg'KP 3TWMW �WjdFl chanical 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: VTaer(s eci a ui ment type and model in Section E on Page 2). ❑ Other(s eci equipment a and model in Section E on Page 2). D: E --�7 Tan ID: �G—t --z—� ank Gauging Probe. Model: �+1 -Tank Gauging Probe. Model: 61 ''S ular Space of Vault Sensor. Model: Annular Space or Vault Sensor. Model: ng Sump/Trench 5ensor(s). Model: M. .O�Piping Sump/Trench Sensor(s). Model: .?�� /Sump Sensor(s). Model: ill Sump Sensor(s). Model:hanical Line Leak Detector. Model:ST ',140-Q- t Fi,d ❑ Mechanical Line Leak Detector. Model: tronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). 1 ❑ Other(specify equipment type and model in Section E on Pa a 2). Tank ID: T ID: ©L--T ❑ In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ nular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: �ing Sump/Trench Sensor(s). Model: e2 $[J$ ❑ Fill Sump Sensor(s). Model: 1 Sump Sensor(s). Model: �2> , Cl 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 t e and model in Section E on Page 2). ❑ Other(s eci a ui ment type and model in Section E on Page 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: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical bine 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 eci a ui rent t e and model in Section E on Page 2). ❑ Other(specify a ui ment a and model in Section E on Page 2). *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' hecldists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring pment: For any eq . ent capable of generating such reports,I have also attached a copy of the report;(check all that apply); System set-up Alsrm history report EA, Technician Name(print): ly)m,2 Signat Certification No.: ` License. No.:_ O Monitoring System Certification