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V AIM f d*4 _C�p QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLE RATES' FEB 0 6 2004 Post Office Box 36 Thornton, Cat. 95686 (209) 794-0102 FAX 794-0112 ENVIRONMENT HEALTH PERMIT/SERVICES General Information Facility Name: Bldg.No.: Site Address: City: ") 07 Zip: !b � Facility Contact Person: U Contact Phone No.: ( 2 ) �v — a Make/Model of Monitoring System: Date of Testing/Servicing: / / -/ -2 B. Inventory of Equipment Tested/Certified Check thea roriate boxes to indicate ecific a ui menti ected/serviced: Tank ID: 77 / e s / Tank ID: ❑ In-Tank Gauging Probe. Model: f-) ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 74 3 ❑ 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(specifl EquiLiaent a and model in Section E on Page 2). ❑ Other(s2eca Equipment a and model in Section E on Page 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(seecify Sqai ment=e and model in Section E on Pae 2). ❑ Other(s eci uimenta and model in Section E on Page 2). 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). ❑ Dispenser 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. 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 infurination 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 �T Technician Name(print): (/wl /f) Signatorc: Certification No.: f �,- � �.-' License. No.: Page 1 of 3 03/01 Monitoring System Certification