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r <br /> f <br /> 1 _ <br /> S 'QUALITY TESTING OF UNDERGROUND TANKS ATA FfgID <br /> Post 4fJ11ce Pax 36 Thornton, Ca. 95086 (209) 794-0102 FAX 794-0112 <br /> JAN 3 1 2006 <br /> General fi formatio ENVIRONMENT HEALTH <br /> Facility Name: <br /> PERM IT/SERVICEildg. No.: <br /> Site Address: 'ACl F1 \l� `.hTG City: C SCA �t�hJ Zip: <br /> Facility Contact Person: Contact Phone No.: ( D 0�1 )C1 E�4 I Lj q d <br /> Make/Model of Monitoring System:X �`-7 L Date of Testing/Servicing: R / /- <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ro riate boxes to indicates ecific_e�ui roenl ins ected/serviced: <br /> Tank ID. 1 4 Tank 10D: 1f 1 <br /> Cl In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑`Annular Space or Vault Sensor. Model: -:F:;, Or Annular Space or Vault Sensor. Model: LS-- .4 <br /> id Piping Sump/Trench Sensor(s). Model: S Ef Piping Sump/Trench Sensor(s). Model: 5 ' <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 equipment and model in Section E on Pae 2). ❑ Other(specify ui ment ty2e 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 /> ❑ 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 equipment a and model in Section E on Page 2). ❑ Other(s eci a ui ment to e and model in Secti on E on Pae 2). <br /> Dispenser ID• , _ Dispenser ID: � . <br /> ❑ Dispenser Containment Sensor(s). Madel: {] Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). O Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). �Jt(f ❑ Dis eraser Containment Float(s)and Chain(s). Yr t <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 ED: <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 Plot Plan showing the layout of iitottitoring equipment For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history report <br /> Technician Name(print): L, 1 r �I <br /> Certification No.:. C" ' f, License. No.: a <br /> 1CC t� J2149115 - u <br /> Monitoring System Certification <br />