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A _E - c _ 'QUAL/TT PEST'/NG OP-UNDFRGROUND 1ANKS'ATAFFORDABLERA7'L S" VIRGWM NT HEAL Post Office Box 36 Thornton, Ca 95 t(209) 94-0102 0pIJES General Information v Facility Name: 7L3,-J' fit L" 1 Bldg.No.: Site Address: / C, crr City: !7 P•aV__OaQ — Facility Contact Person: Contact Phone No.: GE-i Make/Model of Monitoring System:rHLO to 07 l019Z Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate mine equipment inspected/serviced: Tank ID: I 9 t C S f' l Tank ID: P g �- ❑ In-Tank Gauging Probe. Model: ' ❑ In-Tank Gauging Probe. Model: Cl Annular Space or Vault Sensor. Model: > Ln!- 13Annular Space or Vault Sensor. Model: ✓ 5 r" L+/-5 ❑ Piping Sump/Trench Sensor(s). Model: 7 6�e L!L-�i- ❑ Piping Sump/Trench Sensor(s). Model: — ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Seasor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor, Model: E3Other(specify ui ment type and model in Section E on Pa a 2). ❑ Other(specify ui ment type and model in Section E on Pae 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model El Piping Sump/Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 17 Mechanical line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl Tank Overfill/High-Level Sensor. Model: LITank Overfill/High-Level Sensor. Model: ❑ Other(speo;ify equipment(spec type and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Pae 21. Dispenser ID: }- Dispenser ID: 4 ❑ Dispenser Containment Sensor(s). Model' P Ks) 1] Dispenser Containment Sensor(s). Model: 5 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: _ Dispenser ID: LI Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 13 Shear Valve(s). El Shear Valve(s). ODis nser Containment Float(s)and Chain(s). LI Dispenser Containment Float(s)and Chain(s). .(f 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 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): \ ElSystem set-up 13Alarm history report Technician Name(print): I`P � (�--�Signature: Certification No.: GLo 3&"�{^ License. No.: Monitoring System Certification