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e "!1 s • ® TE05 N : • q AM /-%f f i� t I - 'QUALITYTESTIMG OF UNDERGROUND 7AMU AT AEFORDABLERATES' Post Oce Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 Generali&AMU ationFacility Name: S �( ! Bldg.No.: Site Address: . City: , (& Zip: -7 Facility Contact Person Contact Phone 779' SA . Make/Model of Monitoring System: ]/Z S — 'S Date of Testing/Servicing:C?LJ_.L-/O4/ B. Inventory of Equipment Tested/Certified Check thea rd-Mate boxes to indicate _specific equipmentinspected/serviced: FTank ID: ® O L— Tank ID: 6 In-Tank Gauging Probe. Model: L3In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ` ElAnnular Space or Vault Sensor. Model:�z —�Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: 79410 —cgcif' 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 Pae 2). ❑ Other(sp 2quiLinent ty2e and model in Section E on Pae 2). Tank ID: tr o F Tank ID: K D I e_,5 ❑ In-Tank Gaugmng 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:_ `��/o�R� c�10b' ❑ Piping Sump/Trench Sensor(s). Model:2f'!Z a7 80 —01as- L3 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(specifX Equipment a and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Pae 2). Dispenser ID: 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: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). .15 Dispenser ID: 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). I ❑ Dis nser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,96py this form. Include information for every tank and dispenser at the facili 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 ❑Alarm history report Technician Name(print): ® 4c, A610 Signature: (� Certification No.: 4A License.No.. 7 Page 1 of 3 ATG Monitor Form Monitoring System Certification