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1 l- <br /> Af fvrba�Z 't <br /> 'QUALITY TESTING OF UNDERGROUND 7ANKSAT AFFORDABLE RATES' <br /> 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 <br /> General Information / ���� <br /> Faci]ity Name: ` 45 -101-/'oon. Bldg.No.: <br /> ,/ �ycy <br /> Site Address: 17800 WY / / City:_ LA7,41")D Zip: 96$3 6 <br /> Facility Contact Person: ✓�5b/ Contact Phone No.:( 2 09 ) 239-- 7-7( <br /> Make/Model of Monitoringstem: gGiDc� OT T65 3tjG7 / <br /> System: � Date of Testing/Servicing: L_/ LL <br /> o(� <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate ecific a ui menu ins ected/serviced: <br /> Ta ID: ' ZOG Tank ID: b I ESP L <br /> -Tank Gauging Probe. Madel: Z-ln-Tank Gauging Probe. Model:_ "�1GG1( <br /> pular Space or Vault Sensor. Model: Y07 Z , nnular Space or Vault Sensor. Model: <br /> Piping Sump/Trench Sensor(s). Model: 768 ZlPiping Sump/Trench Sensor(s). Model: 208 <br /> ❑ ill Sump Sensor(s). Model: q ❑ Fill Sump Sensor(s), Model: <br /> Mq <br /> echanical Line Leak Detector. Model: /�0 aGDp ,Nechanicid Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify ui menu a and model in Section E on Page 2). ❑ Other(sPEcifv a ui menu type and model in Section E on Pae 2). - <br /> Tank ID: C.7t Tank ID: <br /> -Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> pular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. .Model: <br /> Piping Sump/Trench Sensor(s). Model: 20f3 ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model:l'1C ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(sgecify Squipment a and model in Section E on Pa a 2). El Other(Specify equipment a and model in Section E on Page 2). <br /> Dispenser ID: 't'Z nr apses In: g <br /> 'spenser Containment Sensor(s). Model' - 7DPJ ,kQ_l�ispensu Containment Sensor(s). Model: Z <br /> Shear Valve(s). -1 Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Di user ID: 4- Dispenser ID: <br /> .spenser Containment Sensor(s). Model: - ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ SbearValve(s). <br /> ElDispenser Containment Float(s)and Chain(s). - 13 Distienser Containment Float(s)aod Chain(s). <br /> Di enser ID: q Dispenser ID: <br /> .spenser Containment Sensor(s). Model: /.08 ❑ Dispenser Containment Sensor(s). Model: <br /> .hI Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every Link and dispenser at the facility. <br /> C. Certification .I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Gertitication is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring fg pmenL- For any Pment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): System set-up ]Alarm history report <br /> Technician Name(print):-zf}n!E Al/min /\ Signatur <br /> Certification No.: /A?9 License.No.: L2-9 UT <br /> OWL <br /> Monitoring System Certification <br />