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A:91q�1 i1PL1611 VIS •l9 M ifM l• 'QUALITY TESTING OF UNDERGROUND 7ANJUATAFFORDABLERATES' t 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 General FaciliIn ty Name ' ^ City: Bldg. No.: ) 9 r}B-t�OD)Site Address: //arpr zip: Zt)d SinFacility Contact Person: ua Contact Phone No.:( zO1 ;Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate eafic a ui ment inspected/serviced: Tapk ID: Tank ID: 4 U US Tank Gauging Probe. Model: -til In-Tank Gauging Probe. Model: j randar Sparc or Vault Sensor. Model: _ 13X -,Ltd C ❑ Annular Space or Vault Season Model: .9.X _.C. tDic of Piping Sump/Trench Sensor(s). Model• 4U . ❑ Piping Sump/Trench Sensor(s). Model: . X - A 9 ❑Jill Sump Sensor(s). Modes: 17 Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ri ❑ Electronic Lane Irak Detector. Model: 1.3 Electronic Line Leak Detector. Model: ❑ Tank Overfin/high-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui men!type and model in Section E on Page 2). ❑ Other(specifv a ui ment type and model in Section E on Pa 2). Tank ID: - Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging probe. Moder• ❑ Annular Sparc or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. .Model: ❑ Piping Sump/Trench Sensor(s). Model: 11 Piping Sump/Trench Sensor(s). Model: 17 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(spaa equi2ment a and model in Section E on Page 2). ❑ Other(specifveguipment a and model in Section E on Pae 2). Dispenser IOD: ) )L Dispenser 10n: -5 ❑ Dispenser Containment Seasor(s). Model! ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). - ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ?aC ❑ Di enser Containment float(s)and Chain(s). T" 5 Dispenser ID: Dispenser ID:. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Ds enser Containment Float(s)and Chain(s). O 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). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain 3). '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 id endfied in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this'lperdlicition is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached i copy of the report;(check all that apply): 17 System set-up ❑Alarm history report Technician Name(print): 4e e 1\V't YYi rn n Signature, Certification No.: > O 7t2 f L jJ License.No.: =l - Lj rj - IiL13 1 Cc 5249 15- LlT Monitoring System Certification