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kffarb a� r `T-e ,* 'QUALITY TESTING OF UNDERGROUND 7ANKSAT AFFORDABLE RATES' 0 Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 GeneralInformatio ¢F Facility Name: E(X ` u pt (O-6 /y Bldg. No.: Site Address: Y City: C O t' Zip: Facility Contact Person: (' (,�p q Contact Phone Make/Model of Monitoring System:_ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the ro nate hoxes to indicates ethic equipment ins ected/serviced: Tank ID: ( a}✓ Tank ID: 1'�'l�n_Tank Gauging Probe. Model: ✓I'7 %f -, ❑ In-Tank Gauging Probe. Model: 417 L,>, Annular Space or Vault Sensor. Modell av--'�S° r.:1 ❑ Annular Space or Vault Sensor. Model:_ .C.S -3 rz �g Sump/Trench Sensor(s). Model: Z S -3 /�'.1-. 13 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: - El Tank Overfill/High-Level Sensor. Model: ❑TaOther'specifya ui ment a and model in Section E on Pae 2). 13 'Other(s e e ui ment a and model in Section E on Pa 2). nk ID• i_(�, Tank ID• SIN 5 ❑ In-Tank Gauging Probe. Model: /"7 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor.Z,—Model: t7 W ' W-Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: .0 =3✓ ' ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical 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(sgecifX equipment a.and model in Section E on PMel.2). ❑ Other(specify ui ment a and model in Section E on Pae 2). Dispenser ID: / )`" ;>_ Dispenser ID: �1L'/o El Dispenser Containment Sensor(s). Modell ❑ Dispenser Containment Senaor(5). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). co 13Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). El Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). mY" --' Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). ODis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Roat(s)and Chain(s). *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 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 information 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): I It, I V t Yn ta n Signature: Ll�•�� 7 d3 Certification No.: 2 0 6 S' License. I o�+� WK0 3 llidilK�C' '6iA9\15 — L( L l tZI Nd ..L. Q3 900Z Monitoring System Certification