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C f farba le('t PERMIT/SER'vii, t � z 'QUALITY TESTING OF UNDERGROUND 7ANKS'ATAFFORDABLE RATES' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 (UeneralInformation q JJ Facility Name: 6 , M i (. 75 04/ Bldg.No.: Site Address: l r " Pn � City: Zip: Facility Contact Person:@c Pit"7 04 Contact Phone No.: ( ) 3Ili Make/Model of Monitoring System: f/R. Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the agEropriate boxes to indicatespecific equipment inspected/serviced. Tank ID: L /0 Tank ID: 77 ❑ IryTank Gauging Probe. Model: ail_Tank Gauging Probe. Model: /Yl qQ Annular Space or Vault Sensor. Model: oil`w�Y F��1 p�7�,nnular Space or Vault Sensor. Model: ©ping Sump/Trench Sensor(s). Model:—70 H3 F)Q— 0"Piping Sump/Trench Sensor(s). Model: ❑ Fjll Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: LI'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(specify equipment t e and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Page 2). Tank ID: Tank ID: Cl'y)/Tank Gauging Probe. Model: 442& ❑ In-Tank Gauging Probe. Model: CI.Annular Space or Vault Sensor. Model: a Annular Space or Vault Sensor. Model: � D O Piping Sump/Trench Sensor(s). Model: IW Piping Sump/Trench Sensor(s). Model: ❑ FilWump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model: �7 r '/ � ❑ 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(s eci equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: g D ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(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). *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 ofmonitoring 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 ❑Alarm histery report Technician Name(print): ��/ `P t/- I VV k Signature: a 61 Certification No.: License.No.: � �J ATG Monitor Form Monitoring System Certification