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VaNamne: <br /> Xf fvrba� Tg*r <br /> 'QUALITY TESTING OF UNDF_RGROUND TANKS AT AFFORDABLERATES' <br /> d Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 <br /> ormation <br /> Fcility 7S a 7 ,rht.t-C°-Wt vtcCui Bldg.No.: <br /> Site Address: �q 31 M U �)�S c City: zip: g 5 2 0 5 <br /> Facility Contact Person:T!i ca 1 - Contact Phone No.:(a Gy)9L)( -1 5 :z <br /> �L <br /> _Make/Model of Monitoring System:_L.._N f,Q k Date of Testing/Servicing: D(;?/12-/06 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appmpriate boxes to indicate cdfic a ui ment ins ected/serviced: <br /> Tank ID: A-)D Or"`rte v+{6' Tank ID: Fl Cl (� <br /> Oln-Tank Gauging Probe. Model: AD Tank Gauging Probe. Model: /*4 <br /> XA,nnular Space or Vault Sensor. Model: 1.. 0Annular Space or Vault Sensor. Model:—� 141,5 <br /> ❑ Piping Sump I Trench Smsor(s). Model: ❑ Piping Sump I Trench Sensor(s). Model: <br /> ❑ Fill Sump Seasor(s). Model: ❑ Fill Sump Sensor(s). Model: ' <br /> ❑ Mechanical Line Lank Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> Cl Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: <br /> 13 Other(specify equipment a and model in Section E on Page 2). Cl Other(s a ui ment a and model in Section E on Pae 2). <br /> Tank ID: Tank ID: <br /> ❑ In-Tank Gauging Probe. Model• ❑ In-Tank Giuging Probe. Model• <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. ivfodeL• <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Seaso(s). Model: <br /> ❑ Fill Sump Smsor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model' <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/IEgh-Level Sensor. Model: <br /> ❑ Other(sp22j2 equipment type'and model in Section E on Pa a 2). ❑ Other(sPazifY equipment a and model in Section E on Pa 2). <br /> Dispenser ID: Dispenses ID: <br /> ,O-Dispenser Containment Sensor(s). Model: N A.5 1z bispenser Containment Sensor(s). Model: 4eA- S <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Disperser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID• Dispenser ID:. <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Seusor(s). Model: <br /> ❑ Shear Valve(s). Cl Sbear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Hoat(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> (3Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: <br /> 13 ShearValve(s). ElSbear Valve(s). <br /> 1313ispensar Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every took 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 (eg. 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;(check aft that apply): ❑System set-up ❑Alarm history report <br /> Technician Name(print): L i I P t ki m no[-, Signature. <br /> Certification No.: 2 License.No.: nTI I — Ljtl— 11143 <br /> t CC 52-Lt9)l5- tJi( <br /> Ylonitoring System Certification <br />