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r <br /> POB 36 26515 N. SACTO. BL. [)i[1tir1UOl1S i�OnitOfiil <br /> THORNTON, CA. 95685 Cg' <br /> 209 794-0102 800 524-9087 device Certification <br /> TEST DATE <br /> SITE: <br /> OPERATOR �I r ,�) j (�11 ,()c/ Sidle"# OWNER Lir <br /> ( <br /> $IITICADDRESS yam ` /(vhf ADDRESS <br /> 'Luff 9t r p a Coe <br /> PHONE ( ) - PuONE { ) <br /> MAKE AND MODEL OF MONITORING SYSTEM 6) 4 ,j ( <br /> Contents of Tank r <br /> Capacity of Tank <br /> Type of Product Line: (Gravity, Suction, Pressure). f"J. <br /> INDICATE LOCATION OF THE MONITORING SENSORS TESTES)BY PLACING A YES OR NO IN APPLICABLE BOX: <br /> Annular Space Sensor <br /> Sump Sensor <br /> Dispenser Containment Sensor <br /> /LA) IUD <br /> Electronic Overfill 1 Level q© <br /> Electronic In-Line Leak Detector A-9 <br /> Mechanical Line Leak Detector <br /> In Tank Gauging Device x? ev eg7;7P_2_ <br /> INDICATE THE FOLLOWING BY PLACING A YES OR NO IN APPLICABLE BOX: <br /> Does the monitoring system have audible and visual alarms? �f ¢% <br /> Does the turbine automatically shut-down If the system detects <br /> a leak, fails to operate or is electronically disconnected? ��, X20 00 <br /> Is the monitoring system Installed to prevent unauthorized tampering? <br /> Is the monitoring system operable as per the manufacturer's specifications? ✓�, - <br /> Which continuous monitoring devices Initiate positive shut-down of the turbine? to -P <br /> CERTIFIED TESTER'S IDN <br /> 6-(P L^ Q byv ... <br /> SIGNATI.ME OF CERTIFIED TECHNICIAN P .d <br /> PRINTED NAME OF CERTIFIED TECHNICIAN I�z9 /if <br />