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�I f forba,-Z f0D6 F 'Q UALITY TESTING OF UNDERGROUND 7ANKSATA1761?D4BLL . i LALTH 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0.116 General Information Name: Site Address: / / / GEMAJ City Facility Contact Person: Bldg. No.:�_ toz) i zip: Q.V y6 Contact Phone No,: ( 9 ) 36 - -1 L sw-j Make/Model of Monitoring System: 0"Led- Roc)T SLS- 3fIC-1 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauiument insnectert/spr iPa.ir T3WID: t2l 4— Model: jZl f. Gauging Probe. Model: Space or Vault Sensor. Model:Pn-ular ping Sump / Trench Sensor(s). Model: O ❑ Fill Sump Smsor(s). Model: ,Mechanical Line Leak Detector. Model: EL ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / I3igb-Level Sensor. Model: ❑ Other (s eci ui ment type and model in Section E on Pae 2). Tank II): ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type .and model in Section E on Pace 2) Dispenser ID: I + -z— ❑ dispenser Containment Sensor(s). ,p' ear Valve(s). Dispenser Containment Float(s) and Tank ID: Sin -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 20 Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: &Mechanical Line Leak Detector. Model: � f�iLD- ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s2ccify equipment a and model in Section E on Page 2). oc In -Tank Gauging Probe. Model: ❑ 6nnular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: $ ❑� ll Sump Sensor(s). Model: 2F -Mechanical Line Leak Detector. Model: FX, r ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Mgb-Level Sensor. Model: ❑ Other (spec equipment type and model in Section E on Pace 2). Dispenser ID: � 6 Model' ❑ �D' penser Containment Sensor(s). Model: 0"y5hear Valve(s). . Chain(s). Dis enser Containment Float(s) and Chainf Dispenser ID: -4 ❑)? spenscr Containment Sensor(s). Model: _ Zear Valve(s). -a Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7 `� ❑ �D'spenser Containment Sensor(s). Model.. !a'Shear Valve(s). �is enser Containment Float(s) and Chain(: Disperser ,'i: 1 D;'speuser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑bis enser Containment Fioat(s) and Chain(s). ❑ Dispenser Containment Floats) 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. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Flan showing the layout ofnianitoring a menta For any eq 'p,plent capable of generating such reports, I have also attached a copy of the report; (check all that apply): rA System set-up Alarm histery report Iry Technician Nance (print): Z9AIF A2 i Si Certification No.: License. No.: 11:4 . ' Z2 UT 077 L -g ntq - l u, � Monitoring System Certification