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+ 1 <br /> POB 36 26515 N. SACTO. BL. �;ontinuous Monitoring <br /> f <br /> fj0x.ZjZt�'Z e0# THORNTON. CA. 95686 Q@VTC@ C@rtification <br /> 209 794-0102 800 514-9087' <br /> FEST DATE <br /> �f��+ > b1{ If �71hL_ <br /> SI"I'Lt �{} r lQa4,J''+rOWNER �� JopERATOR ^GtfiADDRESS <br /> SITi ADDR� r �W(r <br /> ��Q C Soe c9 ar <br /> PHONE <br /> r <br /> MAKE AND MDDEL OF MONITORING SYSTFM <br /> � Pt1,°'l— T45 ;z6 J <br /> Contents of I ank <br /> Capacity of Tank 72 " <br /> Type of Product Line: (Gravity, Suction, Pressure). <br /> INDICATE LOCATION OF THE MONITORING SENSORS TESTED BY PLACING A Yl'cS OR NO IN APPLICABLE BOX: <br /> Annular Space Sensor <br /> J <br /> Sump Sensor <br /> Dispenser Containment Sensor <br /> Electronic Overfill J Level . <br /> Electronic In-Line Leak Detector / <br /> Mechanical Line Leak Detector <br /> n '5>��' <br /> In Tank Gouging Device <br /> IWICATI=THE FOLLO"NG BY PLACING A YES OR NO IN APPLICABLE BOX �^n <br /> Does the monitoring system have audible and visual aiannsq i J <br /> Does the turbine automatically shut-down If the system detects <br /> a Ieek, tails to operate or Is aNK"nlcalty disconnected? gj <br /> is the monitoring system Installed to prevent unauthorized tampering?is the monitoring system operable as per the manufacturers specifications? <br /> Which continuous'monitoring devices lnitiate'posltive shut-down of the turbine? <br /> CERTIFIED TESTER'S I00# r V l{- - (2 r <br /> SIGNATURE OF CERTIFIED TECHNICIAN <br /> PRINTED NAME OF CERTIFIED TECHNICIAN <br />