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td 1 i DRY / Af 'QUALITY TESTING OF UNDERGROUND 7ANKS'ATAFF0RDABgAM f'Eg 2097 416 2nd Street Galt, CA 95632 (209) 744- 04"R4#1 6 General Information / Facility Name: O�a�d ��✓�^ I Bldg No.: Site Address: 106-70 Al, /-/W City: SToeIG7o.✓ Zip: Facility Contact Person: �l Contact Phone No.: (.af- 7 H Make/Model of Monitoring System: u70 STi,� Date of Testing/Servicing: L / L /-i�x B. Inventory of Equipment Tested/Certified Cbeck the a2propriate boxes to indicates ecific a ui ment ins ected/serviced: Ta ID: 8T Tank ID: D /E - - Tank Gauging Probe. Model: In-Tank Gauging Probe. Model P A61 ulaz Space or Vault Sensor. Model: GS'3A ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(',). Model: L5-3tQ- Xfiping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: - ❑ Fjll Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model:— [irMcchanical 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(sP=ifY equipment a and model in Section E on Pae 2). T9k IN Tayk ID: Rj Tank Gauging Probe. Model: 0In-Tank Gauging Probe. Model:WA61 9nular Space or Vault Sensor. Model: LS%3A OAmnular Space or Vault Sensor. .Model: 4 Piping Sump/Trench Sensor(s). Model: 1-3•3A- ZI Piping Sump/Trench Sensor(s). Model: ❑ ll Sump Sensor(s). Model: ❑jx"ump Sensor(s). Model: Mechanical Line Leak Detector. Model: R2 Mechanical Line Leak Detector. Model: Q) 7 o vO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Cl Tank Overfill/High-Level Sensor. Model: ❑ Other(speciLl equipment a and model in Section E on Page 2). ❑ Other(specifZ equipment a and model in Section E on Pae 2). Dispenser ID: / `'r`' — Dispenser ID: i _ ❑ Dispenser Containment Sensor(s). Model: - ❑ Dispenser Containment Sensor(s). Model: 11-Shear Valve(s). f21shear Valve(s). IYDispenser Containment Float(s)and Chain(',). JR ispcaser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Zee ❑ Dispenser Containment Sensor(',). Model: ❑ Dispenser Containment Sensor(s). Model: ,Shear Valve(s). ear Valve(s). ails enser Containment Float(s)and Chain(s). kr Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Sbear Valve(s). - ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Crain(',). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identifled in this document was inspected/serviced in accordance with the monufacturers' 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 ej!pment For any eipoknent capable of generating such reports,I have also attached u copy of the report;(check all that apply): /ylf System set-up Alarm histo Technician Name(print): Z/4/Nt,. M110!20 7C' l� Signature: Certification No.: /� License.No.: � UT 077H Monitoring System Certification