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7 <br /> UES' 2003 <br /> QUALITY TESTING OF UNDERGROUND TANKSATAF'FORD.Q 4ERA.T7 <br /> �,Jl <br /> Post Ofee Box 36 Thornton, Car. 95686 (209) 794-0102' "k& - 112 <br /> General Inform tiolL <br /> Facility Name: C>t"' � `��� , �� � ��---� <br /> ,�° Bldg No <br /> Site Address: -R-6 �.p '� ~'1/ City. ,� '' <st 7t <br /> P• <br /> Facility Contact Person: _ Contact Phone No.:(_) <br /> Make/Model of Monitoring System: yi o °'' 1.' S 0 e6 1 Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment i =a/serviced: <br /> Tapk ID: Tank ID: 7 77 <br /> 441 Tank Gauging Probe. Model: 15, Z7 / 0 ( Lj I Tank Gauging Probe. Model:LP3 f <br /> ,Mnular Space or Vault Sensor. Model: SS t"L Lit to nular Space or Vault Sensor. Model: J`5 L <br /> (Piping Sump/Trench Sensor(s). Model:�5a, Pip ng Sump/Trench Sensor(s). Model: fs f <br /> ❑ Pill Sump Sensor(s). Model: ❑ 1 Sump Sensor(s). Model: <br /> Mechanical Lane Leak Detector. Model: 7 ,k Mechanical Line Leak Detector. Model: 4 J —T` <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(s2ecify equipment tvve and model in Section E on P e 2). ❑ Other(s eci ui ment ty2e and model in Section E on Pae 2). <br /> Tank ID: Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: Mn-Tank Gauging Probe. Model: e 11-f- f <br /> ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: i -tv, <br /> ❑ Piping Sump/Trench Sensor(s). Model: dPiping Sump/Trench Sensor(s). Model: " ` ° <br /> ❑ Fill Sump Sensor(s). Model: ❑ Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: -,_T 0 t a '_•-'- <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> FDenr(s a ui rent a and model in Section E on Page 2). ❑ Other(s eci ui rent a and model in Section E on Pae 2). <br /> er ID: Dispenser ID: �'/ <br /> enser Containment Sensor(s). Model' 7- < ❑ Dispenser Containment Sensor(s). Model:J-S P 1 t- <br /> r Valve(s). ❑ Shear Valve(s). <br /> enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> er ID: Dispenser ID: <br /> enser Containment Sensor(s). Model: tie 1- ❑ Dispenser Containment Sensor(s). Model: <br /> r Valve(s). ❑ Shear Valve(s). <br /> enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Maiel: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis user Containment Floats)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history report <br /> Technician Name(print): : 4 ! Signatuic: <br /> Certification No.: ✓D n <br /> License. No.: <br /> Page 1 of 3 03/01 <br /> Monitoring System Certification <br />