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UC -'-H---- FPw%\ 'QUALITYTES'TING OF UNDERGROUND 7ANKSATAFFORD,4B3fj�141q 006 416 2nd Street 744-OIIJV IR ''General Information Facility Name: 'E.._e-- O-T*�QL- Bldg. No.:�_ Site Address: 70/ (4,11s4 dTee �/►% City: STcctz�-r o .� Zip: 95za(o Facility Contact Person: Contact Phone No.:(�D 9 ) �� - Dp Make/Model of Monitoring System: / ^/�� Date of Testing/Servicing: 5 / 5( /per B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecific Paninmrnr i..... t-.ai...___.i. Tank ID: lz�) / InC__r Model: In -Tank Gauging Probe. Model: A I A67 Annular Space or Vault Sensor. Model: E/ 5 Piping Sump / Trench Sensor(s). Model: N tr.s ❑ Fill Sump Sensor(s). Model: 'Mechanical Line Leak Detector. Model: rE �E7Qt� ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tpk ID: 9 / a> <_ -- ,-d In -Tank Gauging Probe. Model: e,7 ❑ nular Space or Vault Sensor. _A4A _ Model: Piping Sump /Trench Sensor(s). Model: G/46 ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:�i"t A ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type'and model in Section E on Pam 2). Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: �. ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment pe and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and Dis nser ID: I Y Containment Sensor(s). Model:Shear Valve(s). FDJpenser ElDispenser Containment Float(s) and Chain(s). Di ebser Dispenser Containment Sensor(s). Model: .YShear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ID: 7 f Model: Model: Model: Model: Model: Model: in Section E on iser Containment Sensor(s). Model: �4 125 Valve(s). iser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(: laic enser ID: _f 6 Die spenser ED: Dispenser Containment Sensor(s). Model: hl �'l ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). El Shear Valve(s). ❑Dis 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 eq 'went capable of generating such reports, I have also attached a copy of the report; (check all that apply);7\System set-upAlam history report f \ Technician Name (print): Z)9/\(FSignature—' Certification No.: �� c�� License. ISo.: __T(�$ •�j"Z ('„ �, �) 7 u t 03771_ Monitoring System Certification