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j QUALITYTESTING OF UNDERGROUND TANKSATAFFORDABLERATES' Post Office Box 36 Thornton, Cay 95686 (209) 794-0102 FAX 794-0112 'GeneralInformation �1 lity Name: _ (7/ A, Bldg. No.:__ Site Address: 1330 City: 1 r i1� Zip: Facility Contact Person:ye h { u fz- Contact Phone No.: (ZOQ Make/M d 1 f V o e o onttortng System: �( M .,= SO- Date of Testing/Servicing: _ 9 / 7 / C S B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enninmPnr �In-Tank Gauging Probe. Model: _ iYA�b.64 1 pular Space or Vault Sensor. Model:_Yip ing Sump / Trench Sensor(s). Model: ill Sump Sensor(s). Model - 7_0$ Mechanical Line Leak Detector. _ Model: 9% LD Z voo ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2)_ ❑ -Tank Gauging' robe. M el; / ❑ nular Space or ault Sensor. del: —ted - ❑ Piping Sump Tinch Sensor(s). del: ❑ ill Sump S s s). odel: Mechanic Lin Leak Detec odel: LA Electr c Line De te r. oriel: ® Overfill / ' - el Sensor. Mo O Other (specify equipment type and model in Section E ppenser ID: 1 Dispenser Containment Sensor(s). Shear Valve(s). Dispenser Containment Float(s) and spens re ID 3.4 -I -j .Dispenser Containment Sensor(s). Shear Valve(s). Dispenser Containment Float(s) and ipenser ID: S .Dispenser Containment Sensor(s). Shear Valve(s). Xspenser Containment Float(s) and Model: 13 Z -7 - Model: Z. Model: Model: *If the facility contains more tanks or dispensers, copy this form Include Tai3k ID:_ -Tank Gauging Probe. , Jr ular Space or Vault Sensor. tng Sump / Trench Sensor(s). ill Sump Sensor(s). Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and Tank ID: P 1_StcL ,qTank Gauging Probe. "nular Space or Vault Sensor. 42 Piping Sump / Trench Sensor(s). .I HU Sump Sensor(s). Mechanical Line Leak Detector. ❑ Electronic line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other knemfv Pm,;nma. r r....e .,..a Model:! Model: X0£3 Model: $ s 7 Model: Zp�j Model: `Ig LDzo00 Model: Model: iodel in Section E on Page 2)_ Model: Model: Model: Model: Model: Model: model in Section E Dis eraser ID: Dispenser Containment Sensor(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Dom' Denser ID: oU Dispenser Containment Sensor(s). RrShear Valve(s). ❑ Dispenser Containment Float(s) and Dis eraser ID• f'� Dispenser Containment Sensor(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: 'W - - Model: z Model: for every tank and dispenser at the facility. C. Certification - I certify that the equipment id filled in document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is infornration g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring uipment For any tent capable of generating such reports, I have also attached a' copy of the report; (check all that apply): ystem set-up rm history report Technician Name (print): Signatw:.: ___ ,......,.._ Certification No.: �� ' License No.: _ 4 SV Monitoring System Certification