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rrx�x� f QUALITY TESTING OF UNDERGROUND TANKSATAI'FUXDABLERATES' VW F�Faci Post Office Box 36 Thornton, Cay 95686 (209) 794-0102 FAX 794-0112Alz him neralI, ormation 'ly Name: 7G� 4'JCUA t' i. 14 ! ; � PE- , 7'� A 71 f�F r „>/Eldg. No .: Site Address: City: Facility Contact Person Zip: Contact Phone No.: ( ) Make/Model of Monitoring System: M 1,14 v ti v -S f, a c-, 0 r 5, d Q `f Date of Testing/Servicing:Z-0-al / LQ :Z B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecitic a ui ment inspected/service Tank ID: 1�' t i ) s ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: _ A !4 / S ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Pae 2). Tank ID• ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment tvae and model in Section E on Page 2) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ED: 13 Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Model: Model: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: _ /N /1 L �i ❑ Piping Sump / Trench Sensor(s). Model: ,' t' ° J ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Pae 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment tye and model in Section E on Pa a 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ DisF. enser Containment Floats) 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. 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 ofmonitoring 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):1 -� f , } Signatw ; Certification No.: License No.: Page I of 3 03/01 Monitoring System Certification