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f.. J f farba,-T 'QUALITY TESTING OF UNl)F..RGROUND 7ANKSAT AFFORDABLE RATES' I Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Information ' Facility Name: LoL){ /c.).6 �•d Bldg.No.: Site Address: t'::�a S C-. '--0C�_.�"c�i21� City: //� _ zip: FacilityContact Person: "� (. -------------_—_-- -- Contact Phone No.: _ 33?, -- Make/Model of Monitoring System:_ �"-}C'.Zl^-.-' ('"jl�� —_ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced+: Tank ID: .R(-A (_ Tank ID: XIn=Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: sT _ Annular Space or Vault Sensor. Model:' -tf(S Annular Space or Vault Sensor. Model: -7_� Piping Sump/Trench Sensor(s). Model:"j L>-L4 U5 ,Mk Piping Sump/Trench Sensor(s). Model::;T�I'LA L S ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: JI�TMechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model:j-E R6Tt2_.I> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ 'rank Overfill/Nigh-Level Sensor. Model: ❑ Tank Overfill/I ligh-Level Sensor. Model: t�T Dispenser Containment Sensor(s). Model:-rS f L4 t. _ Dispenser Containment Sensor(s). Model:-T-C, L J ❑ Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Flont(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chnin(s). ❑ Other(specify equipment type and model in Section I:on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: [l.Sl_ 'Tank ID: In-Tank Gauging Probe. Model: U In-frank (iuugiuq 111ohe Model: _ U Annular Space or Vault Sensor. Model: ,4)(a'T -_Tnok U Annular Space or Vault Sensoi. Model: �--- )W,Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: rte- r(Zs> ❑ Mechanical Line Leak Detector. M0 del: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector'"~ Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ 'rank Overfill/I ligh-Lze l Sensor. Model: Dispenser Containment Sensor(s). Madel: -f'rP e-s QS ❑ Dispenser Contai►5inent Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). 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 al that apply): .IA System set-up '{ 1 Alarm history report. Technician Name(print):L)ITco �(Zt��'��rY�E1(ZI L Signature:_,_ Certification No.: License.No. Phone No.: �l �-`aU�