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'QUALITY TESTING (W UNDERGROUND 7AArKSJTA#FfflTJ TjWt 794-0112 Post Office Box 36 Thornton, Ca 95686 04"A84V Facility Name: '01 Bldg. No.: Site Address: �� % , 7-/i <i/ � e/ %rU City: �{ zip:. V Facility Contact Person: r Contact Phone No.: ( ) Make/Model of Monitoring System: V -R Tk :-Js _ 5� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate meciric a ui meat ins ected/serviced: Tank ID: / e 5' 't_a / IZ /1i 3 b Tank ID: ❑ In -Tank Gauging Probe. Model: t° � ❑ Annular Space or Vault Sensor. Model: Xq/ 4 D 1 6— ❑ In -Tank Gauging Probe. Model: ❑ Piping Sump / Trench Sensor(s). Model: Zg4 3 1&6 -- ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (spe2a Model: ❑ Tank Overfill / High -Level Sensor. Model: equipment type and model in Section E on Pae 2). Tank ID: ❑ Other (specify a ui)ment a and model in Section E on Page 2). ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci Model: ❑ Tank Overfill / High -Level Sensor. Model: Uiiiment a and model in Section E on Pae 2). ther (s eci ui ment and model in Section E on Page 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: rDispenserID: ispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). hear Valve(s). Dispenser ID: Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Sensor(s). Model: L3 Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dis enser Containment Float(s) and Chain(s). El Shear Valve(s). ❑Dispenser Dispenser ID: Containment Float(s) and Chain(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dis enser Containment Float(s) and Chain(s). ❑ Shear Valve(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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (clieck all that apply): ❑ System set -UP ❑ Alarm histery report Technician Name (print): Ll ( I ✓! ¢;FI6 Sgn3iW:: � — t Certification No.: License No.: Monitoring System Certification