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7 POB 36 26515 N. SACTO, BL. Trontinuous Monitoring4 <br />Af <br />farba- Tjeej THORNTON,,_ 95686 Device certification <br />209 794-0102 8 4-9087 <br />P(7 1%SX DATE I - <br />SITE: <br />OPERATOR GP -E 1,-'At <br />SITE ADDRESS <br />PHONE <br />MAKE AND MODEL OF MONITORING SYSTEM <br />Contents of Tank <br />Capacity of Tank <br />Type of Product Line: (Gravity, Suction, Pressure). <br />OWNER ke-le- 60,60-'A I' <br />ADDRESS <br />' PHONE 1 <br />CW- r <br />INDICATE LOCATION OF THE MONITORING SENSORS TESTED BY PLACING <br />Annular Space Sensor <br />Sump Sensor <br />Dispenser Containment Sensor <br />Electronic Overfill / Level 9s <br />Electronic In -Line Leak Detector <br />Mechanical Line Leak Detector <br />In Tank Gauging Device <br />IN APPLICABLE BOX: <br />137 <br />17 Z <br />D, E <br />)2102-`f <br />koeL <br />(,o/6 <br />pat* <br />puss <br />Aejr-5, <br />OR NO IN APPLICABLe UUA. <br />yEs t y1— <br />INDICATE THE FOLLOWING BY rug AIMU n YES OR NO <br />Does the monitoring system have audible and visual alarms? <br />yet) <br />YC <br />. ! <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />yes <br />YIES <br />y1E5 <br />y� s <br />Y I- 1S <br />Y I= <br />5 <br />YESI <br />,149 <br />0 a <br />N v <br />X95 <br />r__ 15 <br />YES <br />YES <br />INDICATE THE FOLLOWING BY rug AIMU n YES OR NO <br />Does the monitoring system have audible and visual alarms? <br />V F:` ' <br />YC <br />. ! <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />Does the turbine automatically shut -down If the system detects <br />a leak, fails to operate or is electronically disconnected? <br />yEs <br />y Es <br />y� s <br />Is the monitoring system installed to prevent unauthorized tampering? <br />yE'S <br />YESI <br />Y S <br />Is the monitoring system operable as per the manufacturer's specifications? <br />X95 <br />yt=s <br />Which continuous monitoring devices initiate'positive shut -down of the turbine. 5- -YAp Sr' 07>©Q - <br />CERTIFIED TESTER'S ID# <br />�,�/_ ;L - <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />. ! <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />/ "07a <br />