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I <br />u <br />,�Affvrbal­l <br />'QU.4L1TY TESTING OF UNDERGRO(IND 7ANKSATAFFORDABLel, Es? 0� <br />416 2nd StreetGalt, CA 95632 (209) 744-0112 F'`Al <br />W.""General Information <br />Facility Name:Ilt <br />2 /� "%' L l - <br />Bldg. No.: <br />Site Address: <br />/ City: —Ld�! Zip: <br />Facility Contact Person: "2..i<'e.Q, <br />'/ Contact Phone No.: (act)_11-L-•&o '� --j <br />Make/Model of Monitoring System: �r'F t` C7r< � �;�; T—���__��-� <br />Date of Testing/Servicing: <br />B. Inventory of Equipment Tested/Certified <br />Check the RpproRriate boxes to indicateecific a uiument inspected/serviced. <br />Tan[ ID: — Tats ID: C_ <br />Jtr Tank Gauging Probe. Model: �1 p�I -Tank Gauging Probe. <br />ofAnular Space or Vault Sensor. Model: Model: r <br />ing Sump /Trench Sensor(s). Model: pular Space or Vault Sensor. Model: <br />Ijping Sump /Trench Sensor(s). Model: v <br />Fr�ump Sensor(s). Model: _ a <br />}p'Mechanical Line Leak Detector. Model: _ (P 1 Sump Sensor(s). Model: <br />t p mechanical Line Leak Detector. Model: <br />❑ Electronic Line Leak Detector. Model: <br />❑ Tank Overfill / High -Level Sensor. Model: ❑Electronic Line Leak Detector. Model: <br />❑ Tank Overfill / High -Level Sensor. Model: <br />❑ Other (specify e ui ment type and model in Section E on Page 2). ❑ Other (s eci a ui <br />Z Tan inept a and model in Section <br />ID: j <br />� 1n -Tank Gauging Probe. Model: In -Tank Giuging Probe. <br />17t anular Space or Vault Sensor. Model: 0/ Model: <br />ular Space or Vault Sensor. Model: <br />,� Pte' ing Sump /Trench Sensor(s). Model: 7 ^� � ping Sump /Trench Sensor(s). <br />-'z rill Sump Sensor(s). Model:Model: Z <br />I � 0'F Sump Sensor(s). Model: . e <br />❑ Mechanical LineLeakDetector. Detector. Model: Mechanical Line Leak Detector. Model: <br />❑ Electronic Line Leak Model: <br />❑ Tank Overfill / High -Level Sensor. Model: ❑Electronic Line Leak Detector. Model: <br />❑ Tank Overfill / High -Level Sensor. Model: <br />EJ (s eci a ui ment a and model in Section E on Pa a 2).C3 Other (s eci a <br />Di enser ID: f Z ui inept a and model in Section Eon Pae 2). <br />Dis��nsei- ID: <br />ispenser Containment Sensor(s). Model's 0"Dispenser Containment Sensor(. Model: <br />Shear Valve(s). l"Shear Valve(s). <br />❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). <br />Di enser ID: y `( Dispenser ID: r <br />=ispenser Containment Sensor(s). Model: 1 L' <br />hear Valve(s). Dispenser Containment Sensor(s). Model _ �cy <br />ElDis enser Containment F7oat(s) and Chain(s).hear Valve(s). <br />❑ Dis enser Containment Float(s) and Chain(s). <br />DIpenser ID: _ 6- T L� D' nser ID: <br />u ispenser Containment Sensor(s). Model: <br />1�btspenser Containment Sensor(s). Model: <br />Shear Valve(s). tn <br />r[ Shear Valve(s). <br />and Chain(s). Dispenser Containment Float(s) and Chain(s). <br />'it the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility. <br />C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) neces <br />correct and a Plot Plan showing the layout of msary to verify that this information is <br />onitoring a pment: For any eq inept capable of generating such reports, I have also <br />attached a' copy of the report; (check all that apply): S stem set-up p Alarm history report <br />Technician Name (print): Z}nlF �// rrir, �n Signature J <br />Certification No.: IIF: License. No.: # 2 9 LLT <br />077 L # ay -1(,� G _. <br />Monitoring System Certification <br />