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PQ v UN 1 4 2004 NVIRONMENTHEAUH PERMIT/VRVICES t 'QUALITY TESTING OF UNDERGROUND TANKSATAFFOIlDABLEItATE Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Information n Facility Name: 1,�.1 (J--� °P r c Bldg.No.: Site Address: ; a"� �� c /, 5 l l , City: Zip: Facility Contact Person:_�ff / // Contact Phone No.: L;109' Make/Model of Monitoring System: C� Date of Testing/Servicing: 1 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific e ui ment inspected/serviced: FLI nk ID: 777 Tank ID: 'f-Tank Gauging Probe. Model: �'I C�' =� 3-5-tank—Gauging Probe. Model- ��i El�nular Space or Vault Sensor. Model: +/ m ?�' �1 b p-anular Space or Vault Sensor. Model.' Piping Sump/Trench Sensor(s). Model r %3''� ❑-g ping Sump/Trench Sensor(s). Model: FiII.Samp Sensor(s). Model: ❑ Fill-Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: U'kechanical 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 a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID• Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 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 ui ment type and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: �— Dispenser ID: ✓ y ❑ Dispenser Containment Sensor(s). Model:P,1�9 ❑ 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: t a Dispenser ID: tr f ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: / e ❑ 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). Moael: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). I ❑ 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 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 ❑Al::rm histery report Technician Name(print): L/Q 2, All yI N7 0 Signatuic: Certification No.: 1:52 License No.:__ q7-//4_73 Prge 1 of 3 03/01 Monitoring System Certification