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W I -ra Is i <br /> 77717, <br /> ���,���,�--�Q�� NOV 1 4 2005 <br /> + ENT HEA <br /> Q UALlTY TESTING OF UNDERGROUND T ANKS'AT AFFORDAB� �F SERV I C ES <br /> lull i i <br /> Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 <br /> General Information—� Q <br /> Facility Name: 1 Pte[`/ �a1F1ED �lL►{eoL�i3Tf2{LT Bldg. No.: <br /> Site Address: Ig75 W. "yVEt.L At/ City: zip: 953"1,6 <br /> Facility Contact Person: Contact Phone No.: M151 - 5C.61 <br /> Make/Model of Monitoring System: f`t" x- 74 Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appmpriste boxes to indicate ecific a ni ment inspected/serviced. <br /> ID: Tank ID: <br /> r.111 <br /> Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> pular Space or Vault Sensor, Model: Lfi•D ❑ Annular Space or Vault Sensor. Model• <br /> ing Sump/Trench Sensor(s). Model: L3• ❑ Piping Sump/Trench Sensor(s). Model: <br /> []_F Sump Sensor(s). Model: El Fill Sump Sensor(.). Model: <br /> chanical Line Leak Detector. Model: L)t�— ❑ Meebanical Line Leak Detector. Model: <br /> ctronic line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:nk Overfill/High-Levet Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(s eci a ui ment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pa 2). <br /> Tank ID: I E'fCC L Tank ID• <br /> ❑ -Tank Gauging Probe. Model: ❑ In-TanLftnbe.g Probe. Model: <br /> pular Space or Vault Sensor. Model: 3 ❑ Annular Vault Sensor. Model: <br /> Piping Sump/Trench Sensor(s). Model: 1.S-6 ❑ Piping rench Sensor(s). Model:❑ 1 Sump Sensor(s). '� Model: ❑ Fill Sur(s). Model: <br /> Mechanical Lane Leak Detector. Model:t:X• 1 V ❑ Mechane Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ ElectroLeak Detector. Model:❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Oigh-Level Sensor. Model: <br /> ❑ Other(s ui ment and model in Section E on Pa a 2). ❑ Other( ui ment a and model in tion E onPae 2 <br /> D eraser ID: Dispenser ID: <br /> spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> D' nser ID: Dispenser ID: <br /> penser Containment Sensor(s). Model: L.S-3 ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ Sbear Valve(s). <br /> ❑ Dis enser Containment Flont(s)and Chain(.). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(.). <br /> *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facili <br /> C. C'ertif cation-I certify that the equipment identitied in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e_g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating an h re rts,I have also <br /> attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history re rt (J /4 <br /> Technician Name(print):,!Qfl e m rY1 E9 Signatur . <br /> Certification No.: I I Q3 Licen –�CO`��e <br /> Monitoring System Certification <br />