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i 'QUALITY TESTING OF UNDERGROUND TANJUAT AFFORDABLE RATES' 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 General Information � � � f Facility Name: /� Bldg.No.: Site Address: 41o416 City: SToc-4 CI" lip; 9 m c Facility Contact Person: Contact Phone No.: O Make/Model of Monitoring System:_ y�EQ to MY: TLS-35 o Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ai ment ins ected/serviced: Tauk ID: 7 oc---F 'Tank ID: An-Tank Gauging Probe. Model: 4 ❑ Ip-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: 20 ,9 ular Space or Vault sensor. Model: iping Sump/Trench Sensor(s). Madel: x.08 Piping Sump/Trench Sensor(s). Model: Zee. ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 'P"-b ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/Mgb-Level Sensor. Model: o2 Tank Overfill 'gh-Level Sensor. Model: 20 POther(specify ui ment a and model in Section E on Page 2). ❑ Other(specify m e men a and model in Section E on Page 2). T ID: Tank ID: -Tank Gauging Probe. Model: 13In-Tank GAuging probe. Model: Annular Space or Vault Sensor. Model: 20 L3 Annular Space or Vault Sensor. .Model: ❑ iping Sump/Trench Sensor(s). Model: 70 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FillSump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: IAO ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: (3 Tank Overfill/High-Level Sensor. Model: Ll Other(s eci equipment a and mode]in Section H on Pae 2). ❑ O[her(specify equip men[ a and model in Section E on Pae 2). Dis eraser ID: I t 7- - Dispenser ID: ispenser Containment Sensor(s). Model: - wr ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ ShearValve(s). ❑ Dis enserContainment Floats)and Chain(s). El Dispenser Containment Floats)and Chain(s). Du enser ID:_ .3 d- Dispenser,Syispenser Containment Sensor(s). Model- 9oP3 ❑ Dispenser Containment Sensor(s). Model: .L1 ShearValve(s). 17 Shearv.alve(s). ❑ Dispenser Containment Float(s)and Chain(s). - ❑ Dispenser Containment Float(s)and Chain(s). Disyyenser ID: Dispenser ID: .Z( ispenser Containment Sensor(s). Model:. 70B ❑ Dispenser Containment Sensor(s). Model: XJ Shear Valve(s). 17 Shear Valve(s). ODis 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 inforuwtion is -correct and a Plot Plan showing the layout of monitoring e9�pment Far any a pment capable of generating such reports,I have also attached of copy of the report;(check all that apply): Idl system set-up Alarm history report - Technician Name(print):. ZRAI F A/�t'20 \ Signature_, Certification No.: License.No.: T(/ 4 5-,21, �3 Z9 - UT OWL # (544- Monitoring 544-Monitoring System Certification