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� 4 <br /> a l <br /> f,. <br /> { <br /> f fjj <br /> CTT <br /> '- ENVIRONMENT HEALTH <br /> 'Q UA LI TY TESTING OF ER <br /> UNDRGOUNF <br /> D 7ANKSATAFORDAMj UTaRVICES <br /> Post Office Box 36 Thornton, Cc. 95686 (209) 794-0102 FAX 794-0112 <br /> S <br /> General Inrmation ' 1) <br /> Facility blame: i V 12 l' h LSt <br /> / Bldg.No.: <br /> Site Address: ` Lt ef k City:: k:Z e+ Zip: G ,�.�,i` <br /> Facility Contact Person: r Contact Phone No.:{_�) <br /> MakeJModel of Monitoring System: Date of Testing/Servicing: �Z I f L5 <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ro riate boxes to indicate speciric equipment ins ectedherviced: <br /> Tank ID: 1-- Tank ID: V, e �' <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> 2Ur-Z6ijjnular Space or Vault Sensor. Model: /— !2f] Cl Annular Space or Vault Sensor. Model: <br /> 'Piping Sump/Trench Sensor(s). Model: l � ❑ Piping Sump/Trench Sensor(s). Model: 4 S — <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(specifl equipment type and model in Section E on Pae 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 /> ❑ 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: Cl Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equi 9ment type and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). <br /> Dispenser ID: Lf I Dispenser ID: Z71_.of <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). Tom' <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: L1 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 monitoring 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 /> f- , <br /> Technician Name(print): ��/� /! !A-%V(i Signature: �' <br /> 1 <br /> Certification No.: License.No.: <br /> Monitoring System Certification <br />