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A ' <br />POB 36 26515 N. SACTO. BL. fflontinuous Monitoring <br />THORNTON, CA. 95686 Device Certification: <br />(20911794-0102 (800) 524-9087 1 _ <br />TEST DATE 3 -9'7- <br />SITE: <br />OP9RATOR ��i4�'!E �,� S118090 <br />OWNER ?67-& <br />Sr=ADDRESS 1361 rv. /le7,r[.fA7AA.) LAN <br />ADDRESS <br />GOD/ CA 9�$ <br />Capacity of Tank <br />PHONE { ) - <br />P11ONE ( ) <br />MAKE AND MODEL OF MONITORING SYSTEM Tv 9 '1 I <br />r...r. � �uTaulrT�u�[d <br />Contents of Tank <br />$ <br />1 <br />5 <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />Capacity of Tank <br />c9c, K <br />/ 6 k <br />/a,e <br />Type of Product Line: (Gravity, Suction, Pressure). <br />�S <br />PSS <br />..� RA^.rrrf%ewr_ Cc/./enoc TceTCn av al wCINr: A YES AR ND IN APPLICABLE BOX. P <br />u T <G <br />U71a16A1C LVVI"IIIVI'1 Vr rnG rnvr�rrvr�rr.v vr.•vv.... .-...�- -. �.�.. _ 1 _ . __ _- - - -- <br />Annular Space Sensoryes <br />-- . .. -- _ <br />C93s3aa'S <br />1 <br />5 <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />Sump Sensory <br />PA O 2-59 0 --o - a <br />�A4 <br />4W,1.Al <br />yss �y <br />3 <br />n" W <br />Dispenser Containment Sensor <br />V(el 5 <br />-- <br />Electronic Overfill / Level <br />Electronic in -Line Leak Detector <br />/VIA <br />Mechanical Line Leak Detector <br />In Tank Gauging Device <br />INnIrATE THE FOLLOWING BY PLACING A YES OR NO IN APPLICABLE BOX: <br />Does the monitoring system have audible and visual alarms? <br />yE� <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />Does the turbine automatically shut -down if the system detects <br />a leak, fails to operate or is electronically disconnected? <br />Is the monitoring system Installed to prevent unauthorized tampering? <br />V(el 5 <br />Is the monitoring system operable as per the manufacturer's specifications? <br />Which continuous monitoring devices initiate positive shut -down of the turbine? -7)txm v <br />CERTIFIED TESTER'S IDS <br />6 2 / as /** 4 <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />ZA h/� M'� /y► <br />z <br />