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Ni_/ _a>/ 'QUALITY TESTING OF UNDERGROUND 7ANKS'ATAFFORDABLE RATES' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 tUeneral Informs in Facility Name: T+ Leo /p7e, n `_- q ,, Bldg.No.: Site Address: `f�� C . M Aa A'1 ao c,yA /JCp� City: C. +_oi TCJ17 l..(.7Y. Zip: , Facility Contact Person: .-II Contact Phone No.: Make/Model of Monitoring System: r in P e) Ir T S 1 n o I Date of Testing/Servicing: B. Inventory of Equipment Tested/Certifled Check thea ro elate boxes to indicates ecce equipment ins ected/seMced: Tank ID: /'P 'P Tank ID: ` ❑ In-Tank Gauging Probe. Model: LIIn-Tank Gauging Probe. Model: C1�lnnular Space or Vault Sensor. Model : 7-$ �t xnular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: F- Piping Sump/Trench Sensor(s). Model: }C 40 fA g.S ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U 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: ❑ Other(specify ui ment type and model in Section E on Pae 2). ❑ Other(specify ui men[type and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Cl Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(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: ❑ Other(specify ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). spencer ID: / V— 1 Dispenser ID: 3 ht Dispenser Containment Sensor(s). Model' ,y-�. L(/5 P Dispenser Containment Sensor(e).� Model:1-S P //J- C] ❑ 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). ❑ 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). DDi5 enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). -If 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): ❑System set-up ❑Alarm history report Technician Name(print): �'//Po "3. /0 1 P led Signature,: =�y�Qj Certification No.: License.Nor��_ZL�' Page 1 of 3 ATG Monitor Form Monitorine System Certification