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t a x I _ kip , i 'QUALITY TESTING OF, UNDERGROUND TAh'KSATAI F'URDABLERATES' Post Dice Box 36 Thornton, Ca, 95686 (209) 794-0102 FAX 794-0112 General fnformatioR Facility Name: ! ki P Cd Z, r-� rf it Bldg.No.: Site Address: SII /Y 1r1 l.%�d�7 City' / ,>X/ 00. Zi 2 r Facility Contact Person: P46ev � �- Pf-- Contact Phone No.: ( ) ?a Make/Model of Monitoring System: I +r ' � �r(lt Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Cheek the approoriate boxes to indicatespecific equipment inspected./serviced: Tank ID: t t� 14 i- Tank ID: c ❑ In-Tank Gauging Probe. Model. ❑ In-Tank Gauging Probe. Model: C]jAnnuJar Space or Vault Sensor. Model:-7 H3`O"b21-_ ❑ Annular Space or Vault Sensor. Model: n ~.�4 < -2,a-3 {"Piping Sump/Trench Sensor(s). Model:—0-b'p P ❑ Piping Sump/Trench Sensor(s). Model: QO,2, i 4 op e=,gl o ❑ F50 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: B'Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pa&e 2). Tank ID: Tank ID: X`J/ ❑ In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: .• r- "" . ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Df=!? ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/high-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). ❑ Other(specify a ui mentty a and model in Section E on Pae 2). Dispenser ID: L Dispenser ID: 1 ;J ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 1 ❑ Dispenser Containment Float(s)and Chain(s). ' Dispenser ID: ) `f- �, Dispenser ID: -,,,X, t1`. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear VaIve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Mo6el: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containcaent Float(s)and Chain(s). I ❑ Dispenser Containment Float(s)and Chain(s). *If the facility cmitains 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 !"formation is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all Mal apply): ❑System set-up 0 Alarm history report Technician Name(print): / } Si natty:-3, Certification No.: License No.: P'lge I of 3 03101 Monitoring System Certification