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*ffjar-,**ITje* PF 'QUALITY TESTING OF UNDERGROUND 7ANKSATArF_0RD.4BLE1?ATES' Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FtV 794-0112 Name: Site Address: 1 21:152� E -C,,,} ��, vylUu —A Bldg. No.: Facility Contact Person: �crr� __F_ City' 1�� Zip: _ I _ Contact Phone No.: [ 2 OG )F�7 - 22� Make/Model of Monitoring System: � (� PiTc � �`(��.� Date of Testing/Servicin • s'a, I-)) Q B. Inventory Tank ID: 12,0L ,d In -Tank Gauging Probe. 'et Annular Space or Vault Sensor. d Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Q' Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. 1] Tank Overfill / High -Level Sensor. Tank ID: 17 In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(,). 17 Fill Sump Sensor(s). ❑ Mechanical line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. 13 Othrr rsn". , Tested/Certified Model: Model: Modei.�9_�1Z9^� Model: Model - JI —�— Model. iodel in Section E o— �j Model: Model: Model: Model: Model: Model: Model: ,R In -Tank Gauging Probe. .@'Annular Space or Vault Sensor. .FrPiping Sump / Trench Sensor(s). 17 Fill Sump Sensor(s). OMceianical Line Leak Detector. ❑ Electronic Line Leak Detector. 13 Tank Overfill / High-level Sensor. ya m- i anx Gauging Probe. P5Annular Space or Vault Sensor. ,IdPiping Sump / Trench Sensor(,). Ll Fill Sump Sensor(s). .0 Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (s eci a ui Model: Model: Model: Model: Model: Model• Model: Model: ya Model: _ Model: _ Model: Model: —� Model: utspenser ID: i 3� meet and mo¢ei in Section Eon Page 2). Dispenser Containment Sensor(,). Model: 13 Shear Valve(s). I)islrenser ID: _ —i 4 ha Dispenser Conmmmen[Sensor(s). Model:,:_ ❑ Dis nser Conminment Float(s) and Chain(s). O Shear Valve(s). ..— Dispenser ID: _ 3 S ❑ Dis enser Containment Hoat(s) and Chain(s). Dispenser Containment Sensor(s). Model: 2 b4> ,D* eraser ID: 4 f 1 i7 ❑ Shear Valve(s). '� llispenser Containinent Sensor(,). Model: 0 Dis eraser Containment Floa[(s) and Chain(,). Shear Valve(,). Dis eraser ID: 4 13 Dis enser Containment Float(s) and Chain(s). Dispenser Containment Sensor(,). Modet: 17 SheValve(s). Dispenser ID: I1 6 /7 Q'Dispenser Containment Sensor(,). Model: l7Dis eraser Containment Floats) and Chain(,). LI Shear Valve(s). *If the facifi contains more Py O Dis enser Containment Float(s) and Chain(,). t5' tanks or dispensers, w this form. Include informstion for every tank and dispenser C. CertlfiCBttOn - I certify that the a[ the facility. equipment identified in this document was inspected/serviced in accordance with the manufacturers' to this Allot is information (e.g. gCertificationthe correct an manufacturers' checklists) necessary to verify that this information is Plan correct and a Plot Plan showing the layout of monitoring eq pment: For any eyui ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alarm hist¢ry report Technician Name (print): 1Y t V11 r^ o Signature,: J --- Certification No.: License. No.:TT! — fir] — �� Wq 3 Cc V 5ZLA91 t5 - Lk j Monitoring System Certification