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APR 0 IZ11 f farba" 7` ENVIRONMENT H 'QUALITYTESTING OF, UNDERGROUND TAAWSATAEFORDABLEp kMT/SERVI Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 General Information Facility Fa y Name: _-)T-",w e"Ilfp Bldg. No.: Site Address: A) X) fiW7- City: Zip: Facility Contact Person: ( ) -.t r"', 4-, Contact Phone No.: (g ) '7113 ct 4; Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate !pecffic equipment inspected/serviced: Tank ED: U" t, Tank ED: El In -Tank Gauging Probe. Model: mw& e 0 In -Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model:71943 RQ- T/ �O 13 Annular Space or Vault Sensor. Model: 13 Piping Sump / Trench Sensor(s). Model:_7 13 Piping Sump /Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: - __70 K_ El Fill Sump Sensor(s). Model: U-MechanicalLine Leak Detector. ModelMechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: ---- Ll Electronic Line Leak Detector. Model: Q Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: E3 Other (s2ecify Sgament =e and model in Section E on P!&e 2). L] Other (specify equipment!) �eand model in Section Eon Page 2). Tank ED: Tank ID: 13 In -Tank Gauging Probe. Model: 13 In -Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: U Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: L] Mechanical Line Leak Detector. Model: E3 Electronic Line Leak Detector. Model: L] Electronic line Leak Detector. Model: Q Tank Overfill / High -Level Sensor. Model: U Tank Overfill / High -Level Sensor. Model: L3 Other (sg= 2guipment type and model in Section E on Pae 2). El Other (specify equipment type and model in Section E on Pae 2). Dispenser ED: ) 9_,;1_ - j U Dispenser ED: Q Dispenser Containment Sensor(s). Model, 13 Dispenser Containment Sensor(s). Model: L j Dispenser 3 U Shear Valve(s). U Shear Valve(s). 0 13 Diseenser Containment Float(s) and Chain(s). Q_ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 13 Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: 0 (3 Shear Valve(s). 13 Shear Valve(s). C3 D Diseenser Containment Float(s) and Chain(s). _2_DisRenser Containment Float(s) and Chain(s). Dispenser ED: Dispenser ED: El Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: El Shear Valve(s). L3 Shear Valve(s). QDispenser Containment Float(s) and Chain(s). 13 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 of monitoring equipment For any equipment capable of generating such reports, I have also attached 2i copy of the report; (cheek all that apply): El System set-up El Alarm histery report <1 Technician Name (print): VAO 2-7, li'llk Signatuie: 2 _D_ Certification No.: License No.: Page I of 3 03/01 Monitoring System Certification