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'QUALI7T7ES77M7OI*,'(INI)rRlr'ROUNI)7ANK.1VX17'Arff)1i/)A% / T;,gP2 ;- iMENT HEALTH Post Office Box 36 7 horn:ton, (. n. 95686 (209) 7�►; 4/s EM -0112 w'General Information Facility Name: - Sar ,_T U- vl Bldg. No.: Site Address: -"7 b 0 b a City: e,*, zip: 9 (' _-76//", r� � . {ntacl Plume No.: N.: y' ( ) %�g --�11 Facility Contact Person:. _ p (� .1 W 6// i Make/Model of Monitoring System: ,llp , V e w c, q % 7 row 4el—s Dale ►l1'I•rsting/Servicing: 11. Inventory of Equipment '1'esled/Cet•lifietl Cbeek thea rorinle boxes to Indicate ecl0c a ul men[ Inspected/serviced: Tank 1D: r✓' e 5 / 'yank ID: fl� U In -Tank Gauging Probe. Model: O in -Tank Gauging Probe. Model: _ -.._ _ _ _ ❑ Annular Space or Vault Sensor. Model: —� �L _ U Annular Space or Vault Sensor. Model: f, 211- S ❑ Piping Sump / Trench Sensor(s). Model: __ A 6.1- 5 _ _._ U Piping Sump / Trench Sensor(s). Model: b YY k 5 O Fill Sump Sensor(s). Milia): U trill Sump Sensnr(A). Model. U Mechanical Line Leak Detector. Model:. _ _ U Mechanical I .ine Leak I )eleclor. Model: ❑ Electronic Linc Leak Detector. Model: U F?lectmnic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: _. U Tank Overfill / Iligh-Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). ❑ Other (specify ui ment type and model in Section B on Page 2). Tank FD- _ __— _ Tank ID: O In -Tank Gauging Probe. Model: O In -'rank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: _ .__ U Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: - .. _ _ U Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: -__ __- _ U Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: .__ _ _ U Mechanical 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: O Other (specify ui rnent type and model in Section E on Page 2). U Other (specify ui ment type and model in Section E on Pap 2), Dispermer TD: Dispenser ID: _�---_---_ 0 Dispenser Containment Sensot(s). Model' U Dispenser Containment Sellsor(A). Model: O Shear Valve(s). U Shear Valve(s). O Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dbpenser ID:_ Dispenser ID: O Dispenser Containment Sensor(s). Mndel: U Dispenser Containment Sensor(s). Model: O Shear Valve(s). U Shear Valve(s). O Di ser Containment Float(s) and Chain(s). U Dispenser Containment Floats and Chain(s). Dlspertser' ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Semor(s). Model: O Shear Valve(s). U Shear Valve(s). Mispensa Containment Floats and Chain(s). ❑ Dispenser r 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 -1 certify that the equipment Identified In this document was Inspected/serviced In accordance with the mnufacturers' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify that this hiternw ba b correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports. I bave abe attached a copy of the re rl; (rherk all aha( apply): U System set-up U ler hbt4try report Technician Name (print ' /ice` _ _ . _.._.__._ Signature:��• �y - ---- Certification No.: _. ` 0 da�� Licrosr. No.: �J.7 `.��.L/..-------- Testing Company Name: Phone No j—`) 1'nRe t of ; 03401 Monitoring System Certification