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. V"F' _ _ _ � �. rer♦ 'a s Y V V77 1 i WI jj n� 'QUALITY TESTING OF UNDERGROUND TAIVIUATAFFORD,4B1��,1' ' Lr' i] 416 2nd Street Galt, CA 956"FC W®4-0112 Ak �44`OII6 ENV : Ri (>eneral Information Jll1'd 1 �? ?006 vut,. +4LL5 Facility Name: U Zr Tt-ltAdtpm. Bldg.No.: Site Address: MGv" 1��1� �L +•• zip: g52o5 Facility Contact Person: Contact Phone No.: at 0wlc1y( -]!5 7 (, Make/Model of Monitoring System:Z lV C,tl t\ ) Date of Testin Servicin B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate eci6c a ui ment ins ected/serviced: Tank ID: 4)O F'F-' -rN n(t'' - - Tank ID: 'u . h TCL br Oln-Tank Gauging Probe. Model: a .H( Tank Gauging Probe. Mo el: JYAru ular Space or Vault Sensor. Model: L ,1,. 1lAnnular Space or Vault Sensor. Model: N h5 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detect,, Model: ❑ Electronic Line Leak Detector. Model: 17 Electronic Linc Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Tank Overfill/ffigh-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specifv ouui ment a and model in Section E on Pa 2). Tank m: - Tank In: ❑ In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model- C1 Annular Spam or Vault Sensor. Model: 1] Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Seasor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 FillSump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Teek Overfill/ffigh-Level Sensor. Model: ❑ Other(specify equiErnent type and model in Section E on Page 2). Q Other(s eci vi ment tYPe and model in Section E on Pa 2). Dispenser ID: Dispenser In: '�'Y ,O'Dispenser Containment Sensor(s). Model: N f-5 �Dispenscr Containment Sensor(s). Model: ❑ Shear Valve(s). 13 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). Cl Dia enser Containment Hoat(s)and Chain(,). Dispenser ID: Dispenser ID:- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(,). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). 11 Dis enser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model-_j ❑ Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). 0 Sbear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). Ll Dispenser Containment Float(s)and Chain(s). OU the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. _ C. Certification -I certify that the equipment identified in this document was inspectedlserviced 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 iayout 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 13 Alarm history report Technician Name(print): L.�I P IA',M'rn n Signature. Certification No.: a22c?& �5 2 License.No.: CT"_ - Gjr7 - Ll 9 CC 14, 52-1-19\15- tk_( Monitoring System Certification