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r • cap I _ F0 t I 1w W7 o 7 4 :4 RD ECE il NOV'QUALITY TEST/NG OF UNDERGROUND IANKSATAFFORDABLERATES'ENVIRO Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 AAMM44),I -S General Inf rmation Facility Name: o<5 p et00� 9 Bldg.No.: Site Address: ��'N O -e / >'. /-� Po City: ///DfI�I��t"�'f'. ZO , Zip: 9 � Facility Contact Person: .Tr n III.X O V7 Contact Phone No.: (�) Make/Model of Monitoring System: CL, 1 C -v t-c o e m C Date of Testing/Servicing: LQ�D! B. Inventory of Equipment Tested/Certified Check the ap2ropriate boxes to indicatespecific a ui ment inspected/serviced. Tank ID: t N 1-- Tank ID: E u S ❑ In-Tank Gauging Probe. Model: LlIn-Tank Gauging Probe. Model: /�4' i— ❑ Annular Space or Vault Sensor. Model: / /HHDb EJ Annular Space or Vault Sensor. Model: I) / ❑ Piping Sump/Trench Sensor(s). Model:( AP.Z,5%20000 ❑ Piping Sump/Trench Sensor(s). Model: a00DOOp ❑ Fill Sump Sensor(s). Model: Ll Fill Sump Sensor(s). Madel: Ll Mechanical Line Leak Detector. Model: ❑ Meebanical 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 Pae 2). ❑ Other(specify ui mentand model in Section E on Pae 2). Tank ID: Tank ID: t� -62 ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 13 Annular Space or Vault Sensor. Model: i a'N ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: x000000 ❑ 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: 1] Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). U Other(specify ui men[type and model in Section E on Pae 2). Dispenser ID: t ZDispenser ID: 1] Dispenser Containment Sensor(s). Model' a -37� ❑ Dispenser Containment Sensor(s). Model: —3;z0 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: -3 t— Dispenser ID: �z tar" ❑ Dispenser Containment Sensor(s). Model: -3ai') ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). • Dispenser Containment Float(s)and Chain(s). Ll Dispenser Containment Float(s)and Cham(s). Dispenser ID: Dispenser ID: 17 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: LlShear Valve(s). LlShear Valve(s). ODis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this forni.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 monitoring equipment. For any equipment capable of generating such reports,I have also attached it copy of the report;(check all that apply): ❑System set-up ❑Alarm history report Technician Name(print): F-f Ao,/7 A) lyn NZ/JSignature:0 �� Certification No.: to License.No.: a ATG Monitor Form Monitoring System Certification