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f f vr <br /> Ic <br /> 'QUAL'TYTE'S'TING OF UNDERGRO(IND 7ANKSATAFFORDABLE1, TES' <br /> Post Office Box 36 Thornton, Ca. 95686 (209) 794-01028FjyjjX�#W`0112 <br /> General Information Z/ VICES h' <br /> Facility Name: F& <br /> Bldg. No... <br /> Site Address: city: ),;7" jU t,, C`4, zip: 67�0 L <br /> Facility Contact Person: <br /> Contact Phone No.: <br /> Make/Model of Monitoring System: Date of Testing/Servicing: _L)�o_"o <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicates ecific e2uienientins pected/serviced: <br /> Tank ED: Tank ID: <br /> t. -C] In-Tank Gauging Probe. Model: "El In-Tank Ganging Protea. <br /> U Annular Space or Vault Sensor. <br /> Model: Ef) =_4 <br /> P Annular Space or Vault Se -0 1_7—1—01: <br /> — Sensor. Model: <br /> El Piping Sump/Trench Sensor(s). Model: ­,70 <br /> Fill Sump Sensor(s). Model: 1) r. El piping Sump/Trench Sensor(s). Model: <br /> 6 'El Fill Sump Sensor(s). Model: <br /> El Mechanical Line Leak Detector. Model: Lj Mechanical Line Leak Detector. Model: <br /> �0 Electronic Line Leak Detector. Model: 9 L <br /> 0 Electronic Line Leak Detector. <br /> Model: <br /> C] Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: <br /> fJ �7A_9,0� <br /> C3 Other(specify equipment type and model in Section E on Page 2). Ll Other(specify equipment type and model in Section E on P <br /> Tank ID:' Tank ED: <br /> El In-Tank Gauging Probe. Model: L) In-Tank Gauging Probe. Model: <br /> Q Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model- <br /> * <br /> 0 Piping Sump/Trench Sensor(s). Model: El Piping Sump/Trench Sensor(s). Model: <br /> El Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: <br /> L] Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: <br /> U Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: <br /> D Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model- <br /> EJ Other(specjhLS9uiyment!ya'and model in Section E on P <br /> El Other(sgeci2_e2uipment!ype:and model in Section E On Page 2). <br /> Dispenser ED: Dispenser ID: <br /> 13 Dispenser Containment Sensor(s). Model! U Dispenser Containment Senso'r(s). Model: <br /> 0 Shear Valve(s). U Shear Valve(s). <br /> 10 Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ED: Dispenser ID: <br /> D Dispenser Containment Sensor(s). Model: L3 Dispenser Containment Sensor(s). Model: <br /> LJ Shear Valve(s). 13 Shear Valve(s). <br /> 11 Discenser Containment Float(s)and Chain(s). 13 Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ED:, <br /> Dispenser ID: <br /> 13 Dispenser containment Sensor(s). I'viodti: Q Dispenser Containment Sensor(s). Model: <br /> D Shear Valve(s). U Shear Valve(s). <br /> DDiseenser Containment Float(s)and Chain(s). 03 Dispenser Containment Float(s)and Chain(s). <br /> *If 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) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout ofmonitoring equipment; For any equipment capable of generating such reports, I have also <br /> attached a*copy of the report;(check all that apply): U System set-up L1 Alarm histery report <br /> Technician Name(print): L l I t, Signature:Certification No.: License, No.: <br /> CC- � .52149 1 5 - Lk T <br /> Monitoring System Certification <br />