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QUAL/TYTESTINGOFUNDF�GROfINDTANKSPPIt(�14@�� � ' <br /> SAN UdU i 1 C U _. <br /> Post Office Box 36 Thornton, Ca. 95686 (�2dd19�2A1UX 794-0112 <br /> EA TH DEPARTMENT <br /> (>eneral Information <br /> Facility Name: M AK)T c C�, 4:�C)C) Bldg.No.: <br /> Site Address: : O tA /l) 5'T Cin,; !12A-At-re-G4 ZiP x/733 <br /> ,CC <br /> Facility Contact Person: Contact Phone No.: SSO <br /> Make/Model of Monitoring System: 1)g42- RD� 5 - 3 U Date of Testin Servicin `tE <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appAriate boxes to indicate specific equipment ins ected/mrviced: <br /> Tan ID:_ T c tC -r Tank ID: D I ESESInL <br /> -Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: <br /> alar Space or Vault Sensor. Model: fd�Annular Space or Vault Sensor. Model: i36- <br /> Piping Sump/Trench Sensor(s). Model: 5 Y 3S6 `7 Piping Sump/Trench Sensor(s). Model: 38D- ZoB <br /> 13 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> echanical Line Leak Detector. Model: eebaiiical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Levet Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify a ui . EI Other(specify equipment a and model in Section E on Pae 2).nentnonaa ) <br /> Tank ID: OC-. Tank ID: <br /> In-Tank Gauging Probe. Model: ❑ 1n-Tank Gar g�ch <br /> be. M <br /> ,O-Annular Space or Vault Sensor. Model: - O ❑ Annular S ceorult Sensor, odel <br /> Piping Sump/Trench Sensor(s). Madel: ❑ Piping mp/Tr Sensor(s). Mode. <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill S p Sense (s). Mod <br /> ZI-Mechanical Line Leak Detector. Model: ❑ Me anical Lin Leak Detec r. M <br /> ❑ Electronic Line Leak Detector. Model: ❑ E cuonic Line Det or. Me el: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ ank Overfill/ i h- el Sensor. Me el: <br /> ❑ Other(s eci equipment a and model in Section E on Pae 2). ❑ Other(s eci a ui ment a and model i ec6on E on Pa a 2). <br /> Dispenser ID: '( a' 2 kT <br /> ID: <br /> ❑ Dispenser Containment Sensor(s). Model: er Contain nsor(s). d <br /> ❑ Shear Valve(s). alve(s). <br /> ❑ Dispenser Containment Floats)and Chain(s). er Coat ' ent oat(s)an Chaff s). <br /> Dispenser ID: :❑ Dispenser Containment Sensor(s). Model: r ntainment enso . Mode❑ Shear Valve(s). e(s).rDispenser <br /> er Containment Float(s)and Chain(s). r Containment Float(s)and Chains . <br /> ID Dispenser ID:Contain t Sensor(s). o e. Dispenser n t Sensor(s). e.alve(s) JShzarralve(s). <br /> r Containment s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information ( .g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring - 'pment. For any eir9kent capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): System set-up AAla rm history re ort <br /> Technician Name(print): IN D Signatwe: <br /> Certification No.:_ I 10-5 License. No.:__. 04- lk it <br /> Monitoring System Certification <br />