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iT t1 U 51 .flGeneral m I! DEC 7 200¢ 'QUALITYTEMNGOFUNDERGROUND IRNKSATAFFORDA )?A TES'�r1HONMENT HE4�Ta Post Office Box 36 Thornton, Ca. 95686 (209) 794-016-2k 70i-_0112 Information t Facility Name: _ u -1E —7,�-r ,a - —7 _ Bldg.No.: Site Address: e r-- k" r �"N, City: 'Loi, I Zip: q 5 2_1/10� Facility Contact Person: A LeCA YL �i Ai t.Lf� Contact Phone No.: (_O 9 } �6-7- 3 4 55 Make/Model of Monitoring System: Vf5bj52 9-ou—r `TZ-- Date of Testing/Servicing. 12-1 r / o?C B. Inventory of Equipment Tested/Certified Check the a pro riate boxes to indicate s ecific equipment ins ected/serviced: T nk IR G -7 Tpk ID: In-Tank Gauging Probe. Model: &1A C!, / n-Tank Gauging Probe. Model: m A C I Annular Space or Vault Sensor. Model:_ 79y360 `/zCanular Space or Vault Sensor. Model: 413 ii 0 fPiping Sump I Trench Sensor(s). Model: W4/360- 208 Piping Sump/Trench Sensor(s). Model:_79'/380- Z©8 ill Sump Sensor(s). Model: ❑ ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:.rX-I V Mechanical Line Leak Detector. Model: Tfl—p 0 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Ll Tank Overfill/High-Level Sensor. Model- ❑ ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify a ui menk type and model in Section E on Pae 2). Tank ID• Tank ID• _D i£'S E t,. '.. ❑ In-Tank Gauging Probe. Model: Xln-Tank Gauging Probe. Model: A G ❑ Annular acejk Model: 0 Annular Space or Vault Sensor. Model: 79 V 3 50 2,0 ❑ Pipin Sump/ or(s). Model: I iping Sump/Trench Sensors). Model: `�/3f3ta ❑ Fil ump Se Model: ,ill Sump Sensor(s). Model: ❑ chaniml ector, Mode. Mechanical Line Leak Detector. Model: - r'1/❑ lectronic lintor. Mo l: ❑ Electronic Line Leak Detector. Model: ❑ ank Overfill Senso del: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(s ec" a and model in Section E on Pae 2), ❑ Other(specia a ui meat ty a and model in Section E on P:i�_ 2), Dispenser ID: t Y "L Dispenser ID: } ❑ Dispenser Containment Sensor(s). Model' ❑ Dispenser Containment Sensor(s)" Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ;KDis eraser Containment Float(s)and Chain(s). Dispenser ID: 3 4 Dispenser ID: 746 Kspenser Containment Sensor(s). Model: ❑ ispenser Containment Sensor(s). Model: ear Valve(s). Shear Valve(s). s Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model" L7 Dispenser Containment Sensor(s). Model: Q Shear Valve(s). D Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoringfequipment. For any qui Ment capable of generating such reports,I have also attached a capy of the report;(check all that apply): 14stom set-up Iarm hnistery r port Technician Name(print): -ZA-IVt W1 07 1W a Signatuv: Certification No.: // 3 License No.; 0 24 l6 Page 1 of i i 03/01 Monitoring System Certification