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d D 1 %f d& 0& JAN 1 0 2006 y -"- rc ECE QUALITYTESTING OF UNDERGROUND 7A1VKSATAFF0R LTH PERMITISEMACES Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 . S' General Information Facility Name: " " " LAI l`J VA L, Bldg.No.: Site Address: 3300 s grr City: JTZ '7 O Zip: Facility Contact Person: Contact Phone No.: O Make/Model of Monitoring_System:_Vr r_, 00-0 '7-'L 3043<_ Date of Testing/Servicing: / B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicateecific a ui ment ins ected/ser-deed: rTaD: 7 Q Tank ID: nk Gauging Probe. Model: In-Tank Gauging Probe. Model: &tar Space or Vault Sensor. Model: ❑ nular Space or Vault Sensor. Model: g Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: ump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: anical Line Leak Detector. Model: F9 PE�T'2.4 echanical Line Leak Detector. Model• S?P 1-?Lbonic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model•(specify ui ment a and model in Section E on Pae 2). ❑ Other(s eci a ui ment a and model in Section E on Pae 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: ❑ FillSump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- ❑ Electronic Line Leak Detector. Model- 13 Tank Overfill/High-Level Sensor. MOA: ❑ Tank.Overfill/High-Level Sensor. Model: ❑ Other(s eci equipment and model in Section E on Pae 2). ❑ Other(s eci a ui ment a and model in Section E on Pae 2), RDisp,nser ID• I ` � Dispenser ID• -F 6 spenserContainment Sensor(s). Model: ❑ spenser Containment Sensor(s). Model: ear Valve(s). ear Valve(s). s enser Containment Float(s)and Chain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: `( Dispenser ID ❑ spenser Containment Sensor(s). Model: ❑ 'spenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ris enser Containment Float(s)and Chain(s). L2±spenser Containment Float(s)and Chain(s). enserID: Dispenser ID: ispenser 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 enser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copf 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 'pment: For any a ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-ap Alam istor re ort Technician Name(print):Y_an E i m tin Signat Certification No.: License.No.': Monitoring System•Certification SAM 3_dbA9U 14