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VL/1J/ GV1V 1J.GJ PAA LVJ IYY VliV l� )fes `, ��-- ---- N 1 � V, ( 'QUALITY TESTING OF UNDERGROUND TANOAT AFFORDABLE RATES' f 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 (reneral Information Facility Name: 07�ADd � ✓� Bldg.No.: Site Address: 10e-75 W Y, City: STOek70e✓ zip: Facility Contact Person: Contact Phone No.:(a0 9 ) 93(- is/fx Make/ModeI of Monitoring System: Aw-ro 5-r ee Date of Testing/Servicing: ! // /-Je-7 B. Inventory of Equipment Tested/Certified Check thea ro date boxes toindicnte neeffic equipment' serviced: T ID: gZ - Tank ID: (E Tack Gauging Probe. Model: In-Tank Gauging Probe. Model: p61 alar Space or V salt Sensor. Mold: !S 3A ❑ ular Space or Vault Sensor. Model: Piping Sump/Trench Sensor('). Model: L5-3A- �ng Sump/Trench Semor(s). Model: L5- 3A1 ❑�ll Sump Sensor('). Model: ❑�J�Sump Sensor(s). Model: yJ Mechanical Line Leak Detector. Model:,�X� U'Mechaniral Line Leak Detector. Model: FXV ❑ Electronic line Leak Detector. Model ❑ Electronic Une Leak Detector. Model: ❑ Tank OvwrA/IEgh-Level Sensor. Model- 13 Tank Overfill/Fygh-Level Sensar. Model: 1E) Oti,, (specify equi went type and model in Section E on Pa 2). ❑ Other(specify equipmentand model in SecdowE ouP 2). ITn„k ID: / Tagk ID: Tank Gauging Probe. Model: In-Tank Ganging Probe. Model• /OA6( M_Annular Space or Vault Senior. Model: L5-3L ❑Annular Space or Vault Sensor. .Model ,ef Piping Sump/Teach Seasor(s). Model: - LS•3L Rf Piping Sump/Trench Sensor(s). Model - 46-3 It ❑ I Sump Sensor(s). Madel: ❑ urop Seasor(s). Model• -Z Mecham Line Leak Detector, Model-FK� idMechanical line Leak Detector. Model: L h 7.000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak detector. Model: ❑ Tank Overfill/High-level Sensor. Model: ❑ Tank Overfill l liigh-Level Sensor. Model• ❑ Other(specify equipment typeand model in Section E on Pa 2). ❑ Other(sped 4 ecruipmcnt and model in Section E oo Page 2). Disperser M: / `s` Iz— - Dispenser - ❑ Dispenser Containment Sensor(s). Model• - - ❑,�Dipenser Containment Sensor(s). Model: Shear Valve(s). - p Shear Valve(s). Rrlhs ser Containment Roat(s)and Chain(s). ser Containment Float(s)and Chain(s).Dispense ID: Dispenser ID: . ❑ Dispenser Containment Sensor(s). Model: O Dispense Containment Sensor(s). Model: ,121"Shear Valve(s). zl ear Valve(s). LI'DiseenScr Contaironent Float(')and Chain(s). W Dispenser Containment Float(s)and Chain(s). Dispense ID: Dispenser ID:. . ❑ Dispenser Containment Sensor(s). Model: ❑ Dispense Containment Sensor(s).- Model ❑ Shear Valve(s). - ❑ Shear Valve(s). 01)isp=w Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the Facility coutains more tanks or dispensers,copy this form. Include information for every tank and dispenser at tdx facility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Gertifi©tion is information (e.g. manufachirenn' checklists) necessary to verify that [bis information is correct and a Plot Plan showing the layout of monitoring e t For any e t capable of generating such reports,I have also attached a copy of the report;(check aff chat apply): System set-ap Y Alsrm histo Technician Name(print)- /--RAI.F �l h m.r>n Signature: Certification No.: License.No.: T(/ .5"24,.t13 2.2 LIT CTrrL � al-l�'1la Monitoring System Certification