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Feb 07 05 01 : 02p Flff la-Test (209' 794-0112 p. 2 W C4 1 • 110 1�G'en�eradl ffarba-TP f CTTQUALITY TESTING UI UNDF_'RGROUND TANKS'ATAFFURDABLL• RATES' Post ®ice Pox 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 Information vv Facility Name: ► � r Ya / Bldg.No.: Site Address: 1 "?5 a 4, City: ), 01( i 4 Zip: Facility Contact Person b2 dl", 6,,Y Contact Phone No.:( ) -5 Make/Model of Monitoring System:'.L/R.2-4-5—__3 Date of Testing/Servicing: / 12 l�� B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment i Tank ID `�.u: Tank ID: ❑ IA-Tank Gauging Probe. Model: f a71_ /112Tank Gauging Probe. Model: Yl 4 Q / Annular Space or Vault Sensor. Model:�.4 �cyO`tel-,;,D0_�znular Space or Vault Sensor. Model: Wiping Sump/Trench Sensor(s). Model:7U H.' 350-�f7Sl Piping Sump/Trench Sensor(s). Model: ?D Sr ❑ �Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: q!��4,rn_=,Cyn ❑ 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(specify equipment and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Page 2). Tank ID: /,J/-,,, Tank ID: ErS-Tank Gauging Probe. Model: `� El In-Tank Gauging Probe. Model: Er ular Space or Vault Sensor. Model: Ja Annular Space or Vault Sensor. Model: y_-Z0 ar Piping Sump/Trench Sensor(s). Model: Q Piping Sump/Trench Sensor(s). Model: n ❑ F�il �ump Sensor(s). Model: El Fill Sump Sensor(s). Model: Cr Mechanical Line Leak Detector. Model: 5 T — G 2 ❑ 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(specify ui mene type and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 4 D ❑ Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cbain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senscr(s). Model-- D odel:❑ Shear Valve(s). ❑ Shear Valvc(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment S_ensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Rif the facility contains more tanks or dispensers,copy this form.`Ioclude 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 ofmonitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that&pply): ❑System set-up ❑ Alarm history report/ Technician Name(prin[):�t>//`� ;t/_ /�/ t 1/YI P17�� Signature: Certification No.: 0/o QLicense.No.: /t74� ATG Monitor Form Monitoring System Certification