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l Affarba-Tr4f �- 'QUALITY TESTING OF UNDERGROUND TANKSATAFFORDUJ VF= Post Office Box 36 Thornton, Ca. 95686 (209) 794-01WUW X�94-0,12 ENVIR(N E7-0 SEE General Information 1 pERMff Facility Name: �N� !i? ' / 2 i/ Bldg.No.: Site Address: `O A)if ✓ City: P: Facility Contact Person: /'J7 Contact gone No.:(a-Q Make/Model of Monitoring System Date of Testing/Servicing: //3/Q5`-" B. Inventory of Equipment Tested/Certified Check the appmpriate boxes to indicatespecific a uiument inspected/serviced: T �` TankIn: nkIQ ❑ In-Tan aging Probe. Model: ❑ In-TanTCCmuging Probe. Model ❑ Annular Spa oVault Sensor. el:' ❑ Annular Space or Sensor. el: ❑ Piping Sump/Tren Senso Model: 1] Piping Sump/Trench Senso Model: ❑ Fill Sump Sensogs). Model t] Fill Sump Sensor(s). :._.,_. LI Mechanical LineJ..e9c Detecm . Model: ❑ Mechanical Ltj e- Detector. Model: ❑ Electronic Leak Detector. Model: ❑ Electroniu Lin Leak Detector. Model: ❑ Ta�IF06�etfill/High-Level Sensor. Model�� ❑ TankDverfill/High-Level Sensor. Model: ❑ Other(s eci equipment a and model in SectioiLE on P G2). LlOther(s eci ui ment and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank 'ng Probe. Mod ❑ In-Tank-Gauging Probe. Model: ❑ Annular Space o t Sensor. del: ❑ Annular Spade or-vault Sensor. Model: ❑ Piping Sump/Trench Sen Model: ❑ Piping Sump/Trench Senso*j. Model: ❑ Fill Sump Sensor(s). ❑ Fill Sump Sensor(s).��' -Model:.,_ ❑ Mechanical Line etector. Model: 0 Mechanical Line,Leak Detector. Model:_ ❑ Electronic Luta Detector. Model: _ ❑ Electronic-Line Leak Detector. Model: Cl Tank Overfill/High-Level Sensor. Model: LI Tank Overfill/High-Level Sensor. Model: 13 Other(specify equipment and model in Section E on Page 2). ❑ Other(specify ui ment and model in Section E on Pae 2). Dispenser ID: at til, )7i y0 Q a.S Dispenser ID: t4.1- 19,a <� ❑ Dispenser Containment Sensor(s). Model' S `3 ❑ Dispenser Containment Sensor(s). Model: Z 1- 13 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: LI Dispenser Containment Sensor(s). Model: Ll Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser In: Dispenser ID: 13 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model:_ El Shear Valve(s). ❑ Shear Valve(s). -- ODis enser Containment Float(s)and Chain(s). 1 ❑ Dispenser Containment Float(s)and Chain(s). .If the facility miltains 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 infurtnation 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 that apply): ❑System set-up ❑Alarm history report Technician Name(print): ��`� ,!/• IL)/4 1yJl!,/�- Signattae: Certification No.: 7C,0`3020/ License.No.: Monitoring System Certification