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QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' , Post Office Box 36 Thornton, Cay 95686 (209) 794-0102 FAX 794-0112 General Informati MAR 1 t 2006 Facility Name: 1 Bldg.:, Site Address: `7621® 1 k_ co'1�l ,3 v d ip r^ � City: i` C.� .� Zips, Facility Contact Person: D a n Me Arn Contact Phone No.: ( zag ) H Lo S - 3 10"j Make/Model of Monitoring System: L ccxk Alrw-i— lkre^.VAYTOLW Date of Testing/Servicing: /_P B. Inventory of Equipment Tested/Certifie Check the appropriate boxes to indicate Mecific equipment iected/serviced: Tank ID: g u(.' Tank ID: I1iese,l ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: E! Alar Space or Vault Sensor. Model: � UCAnnular Space or Vault Sensor. Model:L.KL.S ® Piping Sump i Trench Sensor(s). ModEl Piping Sump/Trench Sensor(s). Model:_L A t_5 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecify a ui ment type and model in Section E on Page 2). ❑ Other(seecify Equipment tyee 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: ❑ Fill.Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s a ui ment qpa.md model in Section E on Pa a 2). ❑ Other(s eci a ui ment typ&and model in Section E on Page 2). Dispenser ID: v C.. Dispenser ID: b I If ❑ Dispenser Containment Sensor(s). Model: l� ❑ Dispenser Containment Sensor(s). Model: e r?�l l/ 13 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certiflcation-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 all that apply): ®System set-up ❑Alarm history report Technician Name(print): ��1ti _ �m Certification No.: /7 �" -f�~ r" <'<' f License.No.:`f CC 5z^4iii5 - LCT Monitoring System Certification