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Seat By: PARTHIAN; 9259731011 • <br /> Aug-10-01 5:15PM; Page 3 <br /> W Pt r' t +). <br /> U <br /> QUALITY TE TING OF-111W RGROUND TANKS'ATAF ORDAELE RATS" <br /> Post Office Box 36 Thornton, Ca 95686 (109) 794-0102 FAX 794-0,112 ti y; <br /> Ger►$ral1Cttformsttia ... <br /> Facility Name: 4 A_r"P10� <br /> Bldg.No <br /> Site Address: {? FaITf -7 ,Q City: &AT_404,('� Zip: <br /> Facility Contact Person: OR— AG_ Ir-._5 - -- Contact PhriitC Ne.: ���} �— - <br /> Make/Modes of Monitoring Systern: <�/ er_ C, Dalc or TestinglServicing: <br /> ._ inY=tatr'YgfEgIj.1PW UtTested/Certileed <br /> Chatsiit tbq.trPe.reP4te boxes to Indicatespecific ul ment Ins tt etlservlcettf• <br /> snit ID'— 7 -_4�r _ Tnnk I fa: <br /> 9(to-Wank Gauging Probc. Mad ck m8k;' T lti-'t'unk Guugiag Probe, Model: <br /> Annular Space or Vault Sa mr. Moc#el: 4�$gf�r{bnr� Uk Annular Space or Vault Sensor: <br /> 1 'Filing Sump//Tt:ench Sensor(s). Mattel. CVPiping Sump/Trench gansogs). Mudd: <br /> Q Fill Sump Senswa), Model, Q Fill Sump Sensor($)_ Model: <br /> Machaatc l Lime lyrist Detector, Model:_ Mectumical Line Leak Detector. MOO* <br /> UEicq tto Luse Uk Deter. . Model: _ lrl Electronic Litre Leak.Deteciar. Model: <br /> Q Tank Ovedltt l 1111gh-Level Sensor. Madel: Q Tank Ove>rlll I ligh-Level Stnsar. Model: <br /> D 61gmtsar Containment Scosor(s). Model . Irl piwnser CoptainmcnI Sctisur(s). Madel:; <br /> Q Show Valve(s). U shear Velvets). <br /> Q Dispenser Containment Floal(s)and Chain(s). C] Dispenscr Containment Fiaal(s)and Chain(s), . <br /> Cl Other( i t+i ent!M and model in SeCriun E011 Page 2). (2 Other(specify equi matt type and model in Section 0 an 2. <br /> Tank ID•--17- -row Tank ID: _ <br /> Af la-Tank Gauging Probe. Model: C,,- C] In-Tank Goosing Probe. Model. <br /> S <br /> ArA narlaa Space or Vault Sonsor. Modcl:— {t( tXs�c+ 0 Annular Space or Vuult Sensor. <br /> ,Piping Sump/Tmnch Sensor(s). Model: 0 Piping sump/,menti Scnsor(s). Model: <br /> 0 Fill Swop Sawor(s). Model: D Fill Sump Sensor(s). <br /> %,Mwbattiod lane Leak Eeteclor. Model:o ij2„{j$,f Z D Mechanical Line leak Detects Madel. <br /> Q Electronic Line Leak Detector, model: -- Q Electronic Line leak I)eyacror. mo" <br /> Q Tank Overfill f High-Level Sensor. Model: ❑ Tank Overfill I Hi ¢vet Scns,or. Model:. <br /> Q Diwcom Cuomo PP=t Sensor(s). Modem _ ❑ Dispenser C nmcnt SCnsnr(S). Model: <br /> I"D Cwt Fkwl(t)mad Chain(s)- C] of ser c;antaintnent Floats)and Chain(*). <br /> [t t]Itrer( 1 ul ont and model In Section L cert Pole 2). O Other{ cliy a u) rnent t• and mods)in Scctiast B on 2 <br /> C. CerIffi ation - I certify that the equipment identified in this document was inspected/serviced in aceordt eww1lb the <br /> manufacturer' guldeltnes. Attached to this Certification Is Information (e.g. manufacturers' to <br /> verity that this Information is correct and a -VLLlPlan showing the layout of monitoring equipment. 0, `apy <br /> ' <br /> equipment Capable of generating such reports, I have also attached a copy of the report, (cheek all that appor): <br /> ---- Systelo xtd-np . <br /> Technician Name(print) O rrrc Alartnh+ ary 7rt <br /> gnat <br /> li t e N <br /> Phone Nn-: — <br />