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1 AUG 0 3 f f arbor•qlr,$iENVIRONMEN PERMIT/SE 'QUALITY TESTING OF UNDERGROUND T ANKS AT AFFORDABLE RATES' Post Office Box 36 Thornton, Ca. 95686 Name: s-�, to Site Address: D . L 4-e Di vi Facility Contact Person: `..' �` 4 Make/Model of Monitoring System: i.'+`:' V'' B. Inventory of Equipment Tested/Certified Ph -1, rho wnmmnrinti- hnxes to indicate snerifie enuinment insnertedkerviced: (209) 794-0102 FAX 794-0112 B1dNo. City: �, e s'a �- -,=(r % j/ P _ Contact Phone No.: �r�b Date of Testing/Servicing: / ! / S'J- Tank ID: Z7 / e S4 / Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: !1%-7 '41�, 5� ❑ Annular Space or Vault Sensor. Model: 7 %/--- L3 Annular Space or Vault Sensor. Model: ElPiping Sump /Trench Sensor(s). Model:' ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 15 01-1 LW ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: FX 11) V ,X. eZ ❑ Mechanical lane 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 (specify ui ment type and model in Section E on Pae 2). ❑ Other (specify equipment a 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 (specify equipment a and model in Section E on Pae 2). ❑ Other (svecifv equipment type and model in Section E on Page 2). Dispenser ID: 87"/ 5a Dispenser ID: #- -3 Y-- f ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ]- S P U A- ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: # Z- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: f'5 /off d- �z ❑ Dispenser Containment Sensor(s). Model:l- ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ltd >E" �5 S ot Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: T U 5 ❑ Dispenser Containment Sensor(s). Model: Ci ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser 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 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): �` y �>D �• l kn W Signature: Certification No.: d License. No.: Page 1 of 3 ATG Monitor Form Monitoring System Certification _