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M� /7 aGr j 2 , 'QUALITY TESTING OF UNDERGROUND T ANKSAT AFFORDffiF RATES I 0N10Eil i ti�-;ai i� 416 2nd Street Galt, CA 95632 (209) 744-011 3'fPF, E�Q116. General Information, Facility Name: �yy S Bldg.No.: Site Address: O e-0"i ,/ sf City: �i�o� Zip: �✓ Facility Contact Person: 5.g,�R' — AAna IJ Contact Phone No.: (2_09 )"9' ` Off-yp Make/Model of Monitoring System: 'rtDate of Testing/Servicing: S / / / C$ B. Inventory of Equipment Tested/Certified Check the a2pr=iate boxes to indicates ecitic a ui ment inspected/serviced: Tank ID: Tank ID: 5 O A In-Tank Gauging Probe. Model: /4 A In-Tank Gauging Probe. Model: s✓ QD Annular Space or Vault Sensor. Model: Zo J1 Annular Space or Vault Sensor. Model: Ud Piping Sump/Trench Sensor(s). Model: 20.E Piping Sump/Trench Sensor(s). Model: JZl Fill Sump Sensor(s). X Z Model: 7—o8 20 B W Fill Sump Sensor(s).X Z Model: 7�a A Mechanical Line Leak Detector. Model: Model: iz�l ❑ Electronic Line Leal: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 ty a and model in Section E on Page 2). Tank ID: _ L— Tank ID: Jit In-Tank Gauging Probe. Model: M RC^ I 4—In-Tank Gauging Probe. Model: $Annular Space or Vault Sensor. Model: ZO 2.Annular Space or Vault Sensor. Model: 5K4A tG 4 Piping Sump/Trench Sensor(s). Model: F3 Jd_L Piping Sump/Trench Sensor(s). Model: toe) AFill Sump Sensor(s). X Z ` Model: J LFill Sump Sensor(s). x -z_. Model: Z >B rg::,S 21-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 type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 1 r`.S e -r k4 Tank ID: ' Jg-In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: JR Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: X-Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Se'nsor(s). Model: &Fill Sump Sensor(s).)x—Z-- Model: ZjO -ZC:''8 ❑ Fill Sump Sensor(s). Model: J"echanical 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 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 kine Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. "t Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci equipment a and model in Section E on Pae 2). 1 ❑ Other(sgeciLl a ui ment and model in Section E on Pae 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' 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 report Technician Name(print):ZW 0- Signature: Certification No.:_/M(] License.No.: �� Monitoring System Certification K)77Z-. 0-1vt