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' Ski'' AUG - 2 2005 QUALITY TESTING OF UNDERGROUND TANKSATAFFORD+M1R ?", of HEALTH Post Office Box 36 Thornton, Cry 95686 (209) 794-0102 FAX 79�0112 General Information Facility Name: r C lr �/ Bldg.No.: �-- a t/ P City: Site Address: � Zip: � + Facility Contact Person: Contact Phone No.:(�'O ol Make/Model of Monitoring System: wi} . Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecific a ui rent ins ected/serviced: Tank ID: k 1,4 G°- Tank ID: 10 ❑ In-Tank Gauging Probe. Model:_ / J ❑ In-Tank Gauging Probe. Model:. z" ❑ Annular Space or Vault Sensor. Model: A. ?"' ❑ Annular Space or Vault Sensor. Model: v �p ❑ Piping Sump/Trench Sensor(s). Model: 9 ❑ 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(s eci ui rent a and model in Section E on Page 2). 13 Other(specify ui ment a and model in Section E on Page 2). Tank ID: ( u Tank ID: ❑ In-Tank Gauging Probe. Model: eo?� 1 ❑ In-Tank Gauging Probe. Model: 4E 4r, , ❑ Annular Space or Vault Sensor. Model: /oma ❑ Annular Space or Vault Sensor. Model: <r" i� ❑ Piping Sump/Trench Sensor(s). Model: r,` ❑ Piping Sump/Trench Sensor(s). Model: a- < ❑ 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(s eci ui ment a and model in Section,E on Pae 2). ❑ Other(s eci equipment a and model in Section Eon Page 2). Dispenser ID: t3 Z lc" / Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 11 l _. Dispenser ID: i :3 d —/ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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). Model: ❑ Shear Valve(s). 13 Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *Ifthe 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 infonnation 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 ❑Alarm history report Technician Name(Print): Sign _�. _ i Certification No.: License No.: Monitoring System Certification