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'QU,4LITYTES'TING OF UNDERGROUND 7AJVL3ATAFF0IiD,4BLE RATES' <br /> 416 2nd Stret halt, CA 95632 (209) 744-01-12 FAX 744- I11b <br /> ti <br /> General IrLformatio�}-� <br /> Facility Name: K 1 0 <br /> City: <br /> Site Address: '11 5� b �t't i- L.�` v t Bldg. No.: <br /> f�IZZ7 .�Cs�-� ,� <br /> �• <br /> Facility Contact Person: �(': 1-C9f' � Zip:/ Contact Phone No.; o�-fl }_��"�/-- <br /> Make/Model of Monitoring System: X "76 Date of Testing/Servicing: <br /> B. inventory of Equipment Tested/Certified <br /> Check the ro riate boxes to indicate 5pecific a ui ment inspected/serviced: <br /> 1Tank ID: t l Tank L'_'.: <br /> T <br /> a In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. <br /> ❑ Annular Space or Vault Sensor. Model: `, R ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump I Trench Sensor(s). Model: ., r::,, �? <br /> ❑ Piping Sump/Trench Sensor(s). Model: 1 4 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model- ❑ Mechanical Line beak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Pae 2). Cl Other(s eci a ui meat a and model in Section E on Pae 2). <br /> Tank ID: Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank G-duging Probe. Madel: <br /> ❑ Annular Spasms or Vault Sensor. Model: El Annular Space or Vault Sensor. <br /> 11 Piping Piping Sump/Trench Sensor(s). Model: C) Piping Sump I Trench Sensor(,). Model: <br /> ❑ Fill Sump Sensors). Model: C3 Fill Sump Sensor(s). <br /> ❑ Electronic Line Leak Detector_ Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Tank OverfilI/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Other(s ec' a ui meat ty a and model in Section Eon Pae 2}, 0 he Overfill eq gph nt tvee and model in Section E on Page 2). <br /> Dispenser ID_ L� Dispenser ID: <br /> ❑ Dispenser Containment Sensor(,). Model: ❑ Dispenser Containment Sensor(,). Model: <br /> r2 j <br /> ❑ S r Valve(,). ❑ Shear Valve(,). <br /> Dis enser Containment Float(s)and Chain(s), yogic. ,2'M5 enser Containment Moat(s)and Chain(s). ;✓� <br /> Dispenser ID: ` Dispenser ID: <br /> ❑ DispeaserContainrnent Sensar(s). Model: ❑ Dispenser Containment 5ensar(s). Model: <br /> ❑ Shear Vaive(s). ❑ Shear Valve(s). <br /> Dis crier Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(sl. <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). <br /> El Shear Shear Valve(s). Ll Shear Valve(s). <br /> ❑Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tames 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 manufactumrs' <br /> guidelines. AWiched to this'arertitication is information (eg. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the iayout of -monitoring equipment: For any equipment capable of generating such reports,I have also <br /> attached a copy of the report; (check afl that apply): ❑system Set-up ❑ Alarm history report <br /> - -- - - <br /> Technician Name(print): LLI C Signature: ✓ j� 4 -r. <br /> 11 11L <br /> Certification No.: <br /> License. No.: <br /> 1 CC fit` Jr 2-Ari 1 5- Ll f <br /> Monitoring System Certification <br />