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r � <br /> �JUAQTYTESTING n1%UNDF!RGRDUXD TANKSATAI'F(lfZl34 <br /> Post Off ee Box 36 Thornton Ca. 95686 (209) 794-0102 FAX 794-0112 <br /> ' ,JAN 8 i 21146 <br /> General Infarmatio ENVIRONMENT HEALTH <br /> Facility Name: f _L17X-N°T L AN�)I-tJ QERMIT/SERVICFlfidg.No.: <br /> Site Address: C.6nc, WC, City: �`fC�C;i� ��i�.� Zip: <br /> Facility Contact Person: Contact Phone No.: ( � )G c:� I - I L-}C <br /> Make/Model of Monitoring System: X -7L Date of Testing/Servicing: I 1I.E-1Q6 <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ro rime voxes to indicatespecific a ai ment inspected/serviced: <br /> Tank ID: 1. 1[ Tank ID: 171 P 1 <br /> O In-Tank Gauging Probe. Model: 13 In-Tank Gauging Probe. Model: <br /> EY Annular Space or Vault Sensor. Model: f_!�p - -:Fp U Annular Space or Vault Sensor. Model: LS A <br /> Z Piping Sump/Trench Sensor(s). Model: i. z> d Piping Sump I Trench Sensor(s). Model: L5 ` <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify ui ment type and model in.Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). <br /> Tank ID: Tank ID• <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ FilI Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment ty a and model in Section E on Pa a 2). ❑ Other(sgeciU a ui ment=d and model in Section E on Pae 2). <br /> Dispenser ID• Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model! ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). U,e ❑ Dis enser Containment Float(s)and Chain(s). Ye <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Piot Plan showing the layout ofmonitoring equipment: For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check aU that apply): D System set-up ❑Alarm history report <br /> Technician Name(print): l y l Signature: <br /> Certification No.: t �: "1L� License. No.: <br /> 1 CC # 62!-iri t 5 - OF <br /> Monitoring System Certification <br />