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TEST DATE <br />y <br />R � <br />u <br />i + fi <br />T <br />MAKE AND MODEL OF MONITORING SYSTEM V `P -Pd-yr- c> oT T\ )- 5 "56E>_ <br />56 t <br />Contents of Tank <br />US <br />12 0)1.19 <br />Capacity of rank <br />1007✓/ <br />6Z) 37 <br />Type of Product Line: (Gravity, Suction, Pressure). <br />�? <br />Sump Sensor 7/ <br />Ye .5 <br />s I V7 t %.\ <br />BY PLACING A YES OR NO IN PLICABLE OX: -e' C®ta rJ9+F'1d5 <br />INDICATE LVA^I1UN yr 1 na irlVMI I VrMnv <br />Does the turbine automatically shut -down if the system detects <br />Annular Space Sensor C W <br />a leak, falls to operate or is electronically disconnected? <br />Sump Sensor 7/ <br />Ye .5 <br />Yv'e <br />Yes <br />Dispenser Containment Sensor <br />Is the monitoring system operable as per the manufacturers specifications? <br />Y'�5 <br />ET 1 <br />Electronic Overfill / Level <br />A-Ff" y <br />z <br />Electronic In -Line Leak Detector <br />D <br />K)o <br />)0 0 <br />Mechanical Line Leak Detector <br />-7 LT <br />In Tank Gauging Device 10717:24 <br />0711;3 <br />7;26- <br />i <br />ime i r%"Un ®V iii Ar%iufl ® VQQ AD bin UJ ®DDI IC®WI R AnY' <br />Does the monitoring system have audible and visual alarms? <br />Does the turbine automatically shut -down if the system detects <br />a leak, falls to operate or is electronically disconnected? <br />Is the monitoring system installed to prevent unauthorized tampering? <br />Y -Pa <br />Is the monitoring system operable as per the manufacturers specifications? <br />Y'�5 <br />ET 1 <br />CERTIFIED TESTER'S Its <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />PRINTED NAME OF CERTIFIED TECHNICIAN r- <br />