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I mrw WR-1 Af firth TQ$f JAN 2 4 7005 QUALITYTESTINGOFUNDIRGROUNDTANKSATAFFORPE VICES H Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 ;neralInformation Mora.da Chevron Facility Name: ✓r n�� ,t��g/�Lf q,, I 2) �Dt� 76- A) (—� % 'y q ` Bldg.No.: Site Address: my t! City: s '1(}Br1 t�-�l Zip: v Facility Contact Person: A(�)�-- ? Contact Phone No.: Make/Model of Monitoring System:_4 ,., ^` n Date of Testing/Servicing: 01j -" B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: 5!�, Tank ID: =? P>-Tank Gauging Probe. Model:--� Y� ❑lank Gauging Probe. Model: Olde Lff Annular Space or Vault Sensor. Model: - S ` Annular Space or Vault Sensor. Model: 4[ Piping Sump/Trench Sensor(s). Model: .®'Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: U Mechanical Line leak Detector. Model:00 "r'g� /�f FNTi/ :-Mechanical Line Leak Detector. Model. 4 L 7�r7L1J D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: 11 Other(specify ui ment a and model in Section E on Pae 2). D Other(s a ui men a and model in Section E on Pae 2). Tank Tank ID: ❑ In-Tank Gauging Probe. Model: r? !- D In-Tank Gauging Probe. Model: !Y!4e D Annular Space or Vault Sensor. Model: cle P ar l7 D Annular Space or Vault Sensor. Model: G t , n jr )Zf Piping Sump/Trench Sensor(s). Model: .R piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ''Mechanical Line Leak Detector. Model:/ -{'ar.6ce/ ieT✓ ;M Mechanical Line Leak Detector. Model: L' Tg, 13 Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: - D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment a and model in Section E on Page 2). D Other(specify ui ment type and mode]in Section E on Page 2). Dispenser ID:_� 9`'�— Dispenser ID: ? `�-- D Dispenser Containment Sensor(s). Model' D Dispenser Containment Sensor(' Model: D Shear Valve(s). El Shear Valve(s). ?-Dispenser Containment Float(s)and Chain(s). f��p .Q.Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser In: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). D Dispenser Containment Sensor(s). Model:DDis mD Shear Valve(s). anan(s). y `O G D Dis enser Containment Float(s)and Chain(s). / f''r Dispenser er Dispenser ID: D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Ll Shear Valve(s). DDis enser Containment Float(s)and Chain(s). D Dis nser Containment Floats)and Chain(s). w]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): ❑System set-up 17 Alarm histery report r Technician Name(print): J—,Il'e17 V t 44,7,"1(� Certification No.: License No.: Monitoring System Certification