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--c t Rf f I� k9? IT ��C QUALITY TESTING OF UNDERGROUND TANKSATAFFORD.4BLERATES' JUL 1 2®p' 416 2nd Street . Galt, CA 95632 (209) 744-0112 FA.X i PERMITISERVI�E S General Info atio�n 1, Facility Name: Bldg.No.: . Site Address: 6 2,3'0 Ar'Gi t; City: .� Zip: Facility Contact Person: Contact Phone No.:( 7(),F ) L-1,e"' /J Male/Model of Monitoring System: VVI ZUD Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a2pro2riate holies to indicate Mecific equipment iected/serviced: Tank ID: IeU I Tank ID: V ❑ In-Tank Gauging Probe. Model: MA-6 ❑ In-Tank Gauging Probe'.. Model:_ _ ❑ Annular Space or Vault Sensor. Model: ®c 7L) GI-Annular Space or Vault Sensor. Model: 13 Piping Sump/Trench Sensor(s). Model7 y U- Z0S' rptng Sump/Trench Sensor(s). Model: 7 Y'�1'� ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: @-Mechanical Line Leak Detector. Model: echanical Line Leak Detector. Model: !7 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: (3 Tank Overfill/High-Level Sensor. Model: ❑ Other( a i ui ment tMe and model in Section E on P!Se 2). ❑ Other(sPEEffX e ui ment a and model in Section E on Pae 2). Tank IDul Tank ID: 0) 13 In Tank Gauging Probe: Model: ErEi-Tank Gauging Probe., Model:� _ U-rKnnular Space or Vault Sensor. Model: .7 ®'c ZO ❑ Annular Space or Vault Sensor. .Model 2-1 ping Sump/Trench Sensor(s). Model: 719 y "' Z 0 8-pipping' Sump/Trench Sensor(s). Model: 7 ❑ Fill Sump Sensor(s).< Model:_ ❑ ump Sensor(s). IModel: U-14whanical Line Leak Detector. Model echanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model• (3 Tank Overfill/High-Level Sensor. Modek ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ui 'ment type and model in Section E on P=2). ❑ Other( eci !211iLnneut=e and model in Section E on Pae 2). Dispenser ID: _Z 3 ' - S Dispenser ID: ✓l} ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s)._Leis- a ❑ Di enser Containment Float(s)and Chain(s).` Dispenser ID: / _/Z Dispenser ID:. — ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment 14oat(s)-and Chain(s). _ .e__f ` ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). .❑ Sbear Valve(s). ❑Dis enser Containzient Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this fora. 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'(�,erdflcation is information (e.g. manufacturers' eheeldists) 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 i copy of the report;(check all that apply): ❑System set-up ❑Alarm history repo Technician Name(print):- i-,ie i Vit M-V71 0 Signature: Certification No.: — License.No..: r,lTi. n 1 CG # 52.49115- u I Monitoring System Certification