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T r � i f fa rba,- t 'QUALITYTES'TING OF UNDERGROUND 7ANKSATAFFORDABLERATES1��, Y23 p? j 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 7444116. HE ! ;ff DEP f R F. a Ueneral Information /i Facility Name: /g,!�A40/`(r &4 C eA Bldg.No.: Site Address: )_t85 F /t4 D N% S-r City: :S f o c-ILToZip: Facility Contact Person:_,S✓A N kA Contact Phone No.: 20 ) 9'3 -b(9 n Make/Model of Monitoring System: VF61)E L 40T -Te-!5 Date of Testing/Servicing: U/d / 0t B. Inventory of Equipment Tested/Certified Check the a2pro2date boxes to indicatespecific a ui ment ins ected/serviced: FUEID: 8—) 0�-T Tank ID: Tank Gauging Probe. Model: A67 -Tank Gauging Probe. Model: +� nular Space or Vault Sensor. Model: 20 Annular Space or Vault Sensor. Model:ONE V iFs55G_cr ping Sump/Trench Sensor(s). Model: 208 iping Sump/Trench Sensor(s). Model: %6g l Sump Sensor(s). Model: ill Sump Sensor(s). Model: 7A8 echanical Line Leak Detector. Model��-/�'1 t-j1 Mechanical Line Leak Detector. Model: 5TP-M_P- D ctronic Line Leak Detector. Model: In Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). T k ID: O c- Tank ID• In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:U NF ESS�l� ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 2 ❑ Fill Sump Sensor(s). Model: \ Mechanical Line Leak Detector. Model: �'fP MLD ❑ 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: VQDther(specify equipment a and model in Section Eon Pa a 2). ❑ Other(specify a ui ment a and model in ection E on Page enser ID:_ (- Z D' penser ID: rj�g ispenser Containment Sensor(s). Model �E ispenser Containment Sensor(s). Model: hear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Hoat(s)and Chain(s). kfDisp,nser enser ID: Dispenser ID: Containment Sensor(s). Model: 22 13 ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). \ is enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats)and Chain(s). enser ID: �� Dispenser ID: ispenser Containment Sensor(s). Model: 8 ❑ Dispenser Containment Sensor(s). ]Model: hear Valve(s). ❑ Shear Valve(s). s 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 of monitoring)�gy�pment For any a �ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): / \ystem Set-up Alarm history report Technician Name(print): Z>4„/� `!�)r�2C7 Signa Certification No.: �� License. o.:�� , 2L 32_7 U-(' 0977 L 1:7� 044- I Monitoring System Certification - - Ss'