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{ 'QUALITYTES'TING OF UNDF_RGRO(IND T�WATAFFORD4BLERATES' 416 2nd Street Galt CA 9502 (209) 744-0112 FAX 744-0116. ' t . General Information Facility Name: O v Cie I `�'C r� Site Address: // Bldg.No.: city:JX � � �+�' Zip: ' �G Facility Contact Person: Contact Phone No.: oZ D Make/Model of Monitoring System: �, 11 -1-0- 7�}L? . Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea roriate boxes to indicates ecitic a ui ment ins ected/serviced: Tank ID: r7 i`� 1 ]`= Tank ID: — A In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model:124,,3 "/foZ� P g P {'1• Model:7Fa Annular Space or Vault Sensor. Model: $(Pim Sum /Tss �` t7 — Qom' j�Piping Sum /Trench Sensors Model: 14j Fill Sump Sensor(s). Model: �p� p O• 7•.0�- al Mechanical Line Leak D t ctor. 1xlodel� .�-f p Fill Sump Sensor(s). Model: a l Vie,,; — M £krhr da Mechanical Line Leak Detector. , Model: e odel: a to �i�re wrN1 ed Tank Overfill/High-Level SSensor. Model: 1 ElDame6uvtpbIodel: ❑ Other(s ecify a ui moot a and model in Section E on Pa a 2). ❑ OtherOverfill (SV ec 11 eHigh-Level m�del Send model in Section E on Page 2). Tank ID: Tank ID: In-Tank Gaugrng Probe. Model: Gl'Cli / 7 ©� `� R V f" (�Annular Space or Vault Sensor. Model: l In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: �fj�',r y� r oy ® Piping Sump/Trench Sensor(s). Model: - 1�1 Fill Sum Sensor(s). R Piping Sump/Trench Sensor(s). Model: apo PModel: '"719 A_FillSump Sensor(s). Model: �+1 Mechanical Line Leak DetectorModel:5T �'1Z ,p f//L/� ❑ Mechanical Line Leak Detector Model: �n 4 V .p Gx,Wv Model:_ a p R ,.: ❑ Tank Overfill/High-Level Sensor. Model: Kgl�vlodel: O Other(Specify a ui ment ❑ Tank Overfill/High-Level Sensor. Model: ( fi' 9 P type and model in Section E on Page 2). 1 El Other(specify equipment type and model in Tank ID: Section E on Pa a 2). ❑ In-Tank Gauging Probe. Model: Tank ID: ' y P 7--r, --- ❑ Annular Space or Vault Sensor. Model: 2'-In-Tank Gauging Probe. Model: ❑ Piping Sump/Trench Sensor(s). Model: �fjnaular Space or Vault Sensor. Model: r (y A/ Fill Sump Sensor(s). Model: f_,rJPing Sump/Trench Sensor(s). Model: � Mechanical Line Leak Detector. Model: pfm ' •ll-i mp Sensor(s). Model: a() ] Electronic Line Leak Detector. Model: et°hamcal Line Leak Detector ] Tank Overfill/High-Level Sensor. Model• (Nyt Iodel: �p� ] Other(spec a ui ment t e and model in Section E on Page 2). ❑ OtherO(sv(specify /eIhug High-Level Sendr.mod lin Section E on Pa a 2). nnk ID: I In-Tank Gauging Probe. Model: Tank ED- ] Annular Space or Vault Sensor. Model: ❑ In-Tank Gauging Probe. Model: 1 Piping Sump/Trench Sensor(s). Model: ❑ Annular Space or Vault Sensor. Model: 1 Fill Sump Sensor(s). Model: ElPiping Sump/Trench Sensor(s). Model: I Mechanical bine Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: Electronic Line Leak Detector. Model: 13Mechanical Line Leak Detector. Model- Tank Overfill/High-Level SenCJ Electronic Line Leak Detector. Model:sor. Model: Other 13Tank Overfill/High-Level Sensor. Model: e a(s eci a ui rnent and model in Section E on Pa e 2). ❑0ther(s eci a ui ment type and f the facility contains more tonics or dispensers,copy this form Include information for every tank and dispenser t model ie facility.on E on Pa e 2). 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' checldists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipmenL. For any equipment capable of generating suds reports,I have also attached a•copy of the report;(check all that apply): 3 U,St m set-up Q_?hrm history report chnician Name(print): V ! rSignak , ' rtificadon No.: t License. No.: nnitor•inb System Cerdflicatiou _ / �).__�/.•'y