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QUALITY TESTING OF (INDE-7FFVDABLE RATES` ALL Post Office Pox 36 Thornton, Ca 95686 (2 ) 794-0102 FAX Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate saecific enninment in.mPef Blag. tvo.: S Zip: Contact Phone No.: ) Date of Testing/Servicing: L /9!�Z/ IO� Truk ID: Tank ID: a In- ark Gauging Probe. Model: Z � (s..) ❑ In -Tank Gauging Probe. Model: ruler Space or Vault Sensor. Model: Q" ❑ Annular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model: q: ❑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 / Higb-Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (seecLfy. a ui ment ty Pe and model in Section E on Pae 2). ❑ Other (s eci equipment type 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: El Tank Overfill /High -Level Sensor. Model: 13 Other (s eci a ui ment a and model in Section E on Pae 2). ❑ Other (specify a ui ment =6 and model in Section E on Pae 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(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). I ❑ Dispenser 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 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 c' Technician Name (print): L,.e.i 1 e �Mrn n Signature: / i f Certification No.: 0 C, 0 License. No.: _�-mi — CC 4 52.49115 - LCF Monitoring System Certification