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Adak + 3. R � i QUALITYTESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' l Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: 9i?ra 0 ��,)y r Olr? r Bldg.No.: Site Address: Z 410 kcv City: zip: Facility Contact Person: Contact Phone No.: (�} ��---- > 9 Make/Model of Monitoring System: j 1:7�x ` �' Lt` Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecitic equipment inspected/serviced: Fnechanical ID: !�'1` tt... Tank ID: Le S -Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. _ Model: nnular Space or Vault Sensor. Model: D�r= ,�, D' ❑ Annular Space or Vault Sensor. Madel: ping Sump/Trench Sensor(s). Model: 7C'R /. ❑ Piping Sump/Trench Sensor(s). Modell ll Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Line Leak Detector. Model:-- L17 d was _ "echanical Line Leak Detector. Model: -_Zoo ❑ Electronic Line Leak Detector. Model: ❑ EIectronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui menk a and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Page 2), Tank ID: Gi fc Tank ID: ❑ In-Tank Gauging Probe. Model: Q In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model:APO ► =' C 13 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: ©-Iftchanical Line Leak Detector. Model: '31- - Q Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: CI Tank Overfill/High-Level Sensor. Model: [❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: d` Dispenser ID -: � l Dispenser Containment Sensor(s). Model: LlDispenser Containment Sensor(s). Model: Shear Valve(s). ElShear Valve(s). Dispenser Containment Float(s)and Chain(s). P- ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: r=l Dispenser ID: - j'- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s), y' ❑ Dispenser Containment Float(s)and Chain(s). [Dispenser ID: 07 /L) Dispenser ID:Dispenser Containment Sensor(s). Model. ElDispenser Containment,Sensor(s). Mo iel: Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s)and Chain(s). !, Q Dispenser Containment Float(s)and Chain(s). k. *If the facility contains more tanks or dispensers,copy this form Include infomlation 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): / vra f rr i Signatui Certification No.: o�Gv, _ License No.: Page 1 of 3 03/01 Monitoring System Certification