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jeneral <br /> an ���� ,iP�'QUALITY TESTING OF UNDERGROUND TANKSATAFFORDAjk AA 1 tPost Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 Information <br /> Facility Name: NAvN1'i'C!y /F_6iCv1� ismer.. Bldg.No.: <br /> Site Address: S�YD A), W a i 4 �LCity: 4- Zip: _;!<_ <br /> T� <br /> Facility Contact Person: tLz!--e,1- n Contact Phone No.:(�;20 -.7- <br /> Make/Model of Monitoring System: Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment iected/serviced. <br /> Tank ID: U ), Tank ID: 5 N s <br /> O In-Tank Gauging Probe. Model: M0 / X n-Tank Gauging Probe. Model: Lv <br /> �xnular Space or Vault Sensor. Model: 2r-Annular Space or Vault Sensor. Model: <br /> I Piping Sump/Trench Sensor(s). Model: - U-171-ping Sump/Trench Sensor(s). Model: 20 <br /> - <br /> O FF' dump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: <br /> * Mechanical Line Leak Detector. Model:F�/ 2-Wre-chanical Line Leak Detector. Model: x� <br /> 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: <br /> 0 Other(specify ui ment type and model in Section E on Pa e.2). 0 Other(specify equipment t e and model in Section E on Page 2). <br /> Tank ID: Tl/-P Tank ID: <br /> O'In-Tank Gauging Probe. Model: Ll- 0 In-Tank Gauging Probe. Model: <br /> a--Anular lar Space or Vault Sensor. Model: 40 od 0 Annular Space or Vault Sensor. Model: <br /> 17 Piping Sump/Trench Sensor(s). Model: '-ZV 0 Piping Sump/Trench Sensor(s). Model: <br /> 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: <br /> R'keehanical Line Leak Detector. Model: 7t 0 Mechanical Line Leak Detector. Model: <br /> 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/Higb-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: <br /> 0 Other(specify equipment a and model in Section E on Page 2). 0 Other(specify equipment a and model in Section E on Page 2). <br /> Dispenser ID: / 4 7-- Dispenser ID: 4 <br /> 0 Dispenser Containment Sensor(s). Model:7 4t30R-7—';;'Q0 Dispenser Containment Sensor(s). Model:-XIA-3 rQ <br /> 0 Shear Valve(s). 0 Shear Valve(s). <br /> 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: <br /> 0 Shear Valvgs). 0 Shear Valve(s). <br /> 0 Dispenser Containment Float(s)and Chain(s). 0 Dis enser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: <br /> 0 Shear Valve(s). 0 Shear Valve(s). <br /> ODis enser Containment Floats)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). <br /> •If the facility contains more tanks or dispensers,copy this form Include infommtion for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached 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 of monitoring equipment For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(checkallthat apply): 0 System set-up 0 Alarm histery report <br /> Technician Name(print):�y,/.� r✓• ✓y" l Il' Signatwr,:A <br /> Certification No.: �'QC++ License. No.:__. ✓/� <br /> Page I of 3 03/01 <br /> Monitoring System Certification <br />