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t � wl a 9 _ Fe'F ITY TESTING OF(JNDF�GRO/(JND 7ANKSATAFF(JRDABLERATES' i'Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112neral Information n Facility Name: LA—1 Y 4DP `� A`: �Ot71 Bldg.No.: Site Address: l � 1 rx W 1.,v City: MANTEGA Zip; 336 Facility Contact Person: J cSs 1r- Contact Phone No.: ( Zc"i ) -Z--59 - 2_7t -7 Make/Model of Monitoring System: t/r E-U P 11 to—r t t S-16n d-_ Date of Testing/Servicing: 101 Z-7 l o B. Inventory of Equipment Tested/Certified Check the approEriate boxes to indicates acute a i ment ins ected/serviced: T LID: ��7 ---r Tank ID: Df 4SF t_ -Tank Gauging Probe. Model: Q In-Tank Gauging Probe. Model: IVI nular Space or Vault Sensor. Model: �O pular Space or Vault Sensor. Model: V O 7 Piping Sump/Trench Sensor(s). Model: '7.oy Piping Sump/Trench Sensor(s). Model: - Zo 8 El frill Sump Sensor(s). Model: 17 Fill Sump Sensor(s). Model: 'Mechanical Line Leak Detector. Model: FXFX 1 — echanical Line Leak Detector. Model: 7� ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 13 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment a end model in Section E on Pae 2). ❑ Other(specify equipment a and model i Section E on Page 2). T cID: O�-T Tank ID: -Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: �� ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Z b� ❑ Piping Sump/Trench Sensor(s). Model: I] Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 1%/C�— ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/I-ligh-Level Sensor. Model: l] Tank Overfill/High-Level Sensor. Model: ❑ Other(s ec equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model byAonPage Dis enser ID- I Z D' user ID: -4 ispenser Containment Sensor(s). Model: ZC>8 UD'spenser Containment Sensor(s). Model: 20 ShearValve(s). -fit Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). D' user ID• `► D' user ID: '1" 'tj ispenser Containnien[Sersor(s . Model: 2 ispenser Containment Sensor(s). Model: O ShearValve(s). hear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)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 Floats)and Chain(s). ❑ Dispenser Containment Hoat(s)and Chain(s). •h`the facility contains more tanks or dispensers,copy 6is fomL 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�pmenk For any a"pment capable of generating such reports,I have also attached a copy of the report;(check off apply): System set-up /& e�larm history report TechZana Name(print): 14 m M n Signature: Certification No.: I R3 _ License.No.: Dl " 1�J7�n Monitoring System'Certiication