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ri�;eneral # far-6arC` eg ;QUALITY TEST.ING OF UNDERGROUND 7ANKYATAFFORDABLERATES'fce Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 ati n Facility Name: h f �Grf V0 P Bldg.No.: % , Site Address: ./ 0 a y P kov ll City: A�. 1""A zip: 9-524c) Facility Contact Person: L I G /y!I Contact Phone No.: 2( O ) ASO -0101 u 3(9 Make/Model of Monitoring System:�P / J,S 3676 Date of Testing/Servicing: _12_/2-/ /_a4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate Mecific equipment fiected/serviced: Tank ID: �'� (.Lj Tank ID: S - jr7 In-Tank Gauging robe. Model 0In-Tank Gauging Probe. Model: ae<1l EY Annular Space or Vault Sensor. Model: of -H n kf Annular Space or Vault Sensor. Model: ,9 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: a-f1 )d Fill Sump Sensor(s). Model: A Fill Sump Sensor(s). Model: ❑ Mechanical Line Irak Detector. Model: ❑ Mechanical Line Leak Detector. Model:i - ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 17 Other(Specify ui ment type and model in Section E on Pae 2). 13 Other(specify ui meat 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: 17 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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: El Tank Overfill/High-Level Sensor. Model: 13 Other(s equipment a and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: / 1F a Dispenser ID: ,u Dispenser Containment Sensor(s). Model:_ --,,AL3Dispenser Containment Sensor(s). Model: Ll shear Valve(s). I] Shear Valve(s). ❑ Dispenser Containment Float(&)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: _7 '(•" Dispenser ID: ,Z Dispenser Containment Sensor(s). Model: 15 0'_ 13Dispenser Containment Sensor(s). Model: 13 shear Valve(s). ' 17 Shear Valve(s). rDispenser Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ser ID: Dispenser ID: Containment Sensor(s). Model: 20 17 Dispenser Containment Sensor(s), Model: arValve(s). ❑ Shear Valve(s). enser Containment Float(s)and Chain(s). Q Dis enser Containment Float(s)and Chain(s). 'Hf 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-op 13 Alarm history report M", � o f�I Technician Name(print):_L 1``1 P I V t m p Signature: . Certification No.: �`n !�� -`- License.No.:_S1'fTl_ - C117- 11143 - 1 CC if 52-49�15 - u(` Monitoring System Certification