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iii rV11A1,17r rr:.S77MG 01;' 17Nl7F.RGROUNl) 7'/f NIE.VA7'Arrr)/fi') „((,4M.FNT HEALTH'' PERMIT/SERVICES Post Office Box 36 Utornroft, C'a. 95686 (209) 794-0142 rAX 794-0112 IF "General Info oration el FacilityNarne: .Pf-� -�--. "a -al Site Address: Facility C'oninct Person: Make/Model etf Monitoring System:. r, 1(,_)491 11. Inventory of Ir tlitipment 'I'esledWerlilie•el Check the aaoro®riate boxes to Indicate specitic equipment Inspected Bldg. No.:J _ - City: � ' 0 zip. _ ('nntncl F'hnor No. ( ? . ).. �✓ __�° ltntenfTesling/Servicin Tank ID: km l4 — ----- 'Tank ID: _—_ _." -- -- R In -Tank Gauging Probe. Mndel: U Irt-'T'nnk f..nrtgine rrohe. Model: nnular Space Model: _ -. -_ - . �zZ _`-°. _ ._ U Annular Space nr. We Model: {ping Sump U piping Sump / {Ker s). Model: ❑ rill Sump Settsot(s). Model: U till Sinop Sensm(s). MIXIel: _ WoWchanical Line Leak 1 tetectot. Modcl: .. chnnical Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ---- -- _. __. _ U Electronic Line Leak Detector. Model: ❑ Tank Overfill / High-level Sensor. Model: _ _ U 'Tank Overfill / High -Level Sensor. Model• ❑ Other (specify ui rnent tXU and model in Section E on Pae 2). U Other s ecif equipment t and model in Section E on Pao 21. Tank II): 'Tank ID: ❑ In -Tank Gauging PPOhC. Model: ------- ___, ._.___ U in-'rnnk Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Modcl' __ _ U Annular Space or Vault Sensor. Model - W -raping Sump /Tie ). Model: -_- _ . U piping Smnp /Trench Sensor(s). Madel: ❑ Fill Sump Sensor(s). Model: U rill Sump Sensor(s). Model: _ f:i ITechanical Line Leak Detector. Mrxicl _ -_ _._.. 1. U Mechnnicni Line Leak Detector. Mwlei: ❑ Electronic Line Leak Detector. Model: -_ _ _ U Fteclionic Line Leak Detector. Model' ❑ Tank Overfill / High-level Sensor. Model _ _ U Tisnk Overfill / Iligh-Level Sensor. Model: R ❑ Other (s ecit ui ment tjEe and model in Section L• on Pae 2). U Other (specify equipment anent t and triode{ in Section E on P o 2 . Dispenser lt):_!1_DR_�"._._ Dispemerll):.--------- __--❑ • Dispenser Containment SenRot(s). Model' . I-fA-s _ U Di.Rpenser Coluniument Selmol(s). Mtxlel: ❑ Shear Vnlve(s). U Sllear Vnlve(s). ❑ Dispenser Containment Floats and Chain(s). U Dispenser Containment Float(sj and Chains). Dispenser ID: 4- op- 6 ------- _-- Dispenser II): ❑ Dispenser Containment Sensor(s). Model' U Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). U Dispenser Containment Fluat(sj and Chains . Dispenser ID: -. _- Dispenser II): - ❑ Dispenser Containment Sensor(s). Model: __. . _ _ _ U Uisltenscr Crtntainment Sensor(s). Martel: ❑ Shear Vnlve(s). (..) Shear Vnlve(s). ❑Dis nser Containment Floats and Chains . U Dispenser Containment Floats and Chains . *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the eynlpmrnt Idenlllied In this docuntent was Iispecled/serviced in accordance with the manufacturers' guidelines. Attached to this Certification Is information (e.g. man facturerx' checklists) necessary to verify that this infor tlon Is correct and a Plot Plan showing (Ile layout it( mmtltnring erluipntent. For any equipment cnpahle of generating such reports, I have also attached n copy of flee report; (cheek all drnf apply): U System Rel -op U Alarm history report Technician Name (print): __--_---__ .__ _ _ - Signnture: -, (:ertiftention No.: (9e7U) OIL? -6"7 Lir ease Nn.: Testing Company Nitnr: I'hnnr No,: Monitoring Syslent Certification Page t of l OYCI