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Hca. v' . r Is rp t <br /> 'QUALITY TESTING OF UNDERGROUND TANK3AT AFFORDABLERATE'S' <br /> 4 f•� <br /> 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 H' <br /> 0 <br /> General Information �/ <br /> Facility Name: - �1�(�7a f�r+V' I AllEL BIdg. No.:� <br /> Site Address: l O°� �. 12l�a�7 V\IA-`l City, Zip: <br /> Facility Contact Person: Contact Phone No.: ( _)-0 1 2 8t� <br /> -Make/Model of Monitoring System: e +�- 42 T TCS- 3 Date of Testing/Servicing: 1 8 I d <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment ins ected/serviced; <br /> VTaID: a G7 Tank ID: <br /> Tank Gauging Probe. Model: / Cl In-Tank Gauging Probe. Model: <br /> nular Space or Vault Sensor. Model: Z� ❑ Annular Space or Vault Sensor. Model' <br /> ing Sump 1 Trench Sensor(s). Model: Zoo. ❑ Piping Sump/Trench Sensor(s). Model: <br /> l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> chanical Line Leak Detector. Model:_FIC`/D ❑ Mechanical Line Leak Detector. Model: <br /> ctronic LincLeak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank OverfiR/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Page 2). Cl Other(SPEEjU equipment a and model in Section E on Pae 2). <br /> T;udc ID: 17( Q C_F Tank 111): <br /> In-Tank Gauging Probe. Model:_j ❑ In-Tank Gauging Probe. Model: <br /> 0 nular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> Piping Sump/Trench Sensor(s). Model: e 6 13 Piping Sump/Trench Sensor(s). Model: <br /> rM Fill Sump Sensor(s). Model: -208 ❑ Fill.sump Sensor(s)_ Model: <br /> Mechanical Line Lealc Detector. Model:_AX-/ 0 ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: (3 Tank Overfill/high-Level Sensor. Model• <br /> 13Other(s ui ment type.and model in Section E on Pae 2). ❑ Other(sEecify equipment a and model in Section E an Pae 2). <br /> Dis enser 1D• r Z Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: <br /> hear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> )a Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dis enser Containment Float(s)and Chain(s), ❑ Dispenser Containment Ploat(s)and Chain(s). <br /> D�is�enser]D: `� Dispenser ID: <br /> ,t3 Dispenser Containment Sensor(s). Model: 26 ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. <br /> C. Certif cation -I certify that the equipment identified in this document was inspected/serviced in accordance with the mmufacture;rs' <br /> guidelines. Atbached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout ofmonitoring equipment For any equ3pment capable of generating such reports,I have also <br /> attached a'copy of the report;(check all that apply): System set-up A Alarm history report <br /> Technician Name(print):- ,c} /F i?n��` Signature: <br /> Certification No.:,--/—/ License.No.: � $ . �( '�%� _f]- U <br /> Monitoring System Certification <br />