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Ab- l_lJUN 1 4 ENVIRONMENT TESTINGOFUNDERGROUND7ANKSATAFFORD„4BLERAT@FRMIT SE 'QUALITY / RVICES Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-OI12 (UeneralInformation 'M Facility Name: Re / eI 7, r MAO- _� � Bldg.No.: Site Address: 1 ZTb IUI I �S F317 W C% City: Z7 �1 41' Zip: Facility Contact Person:-7TTA�t ✓t/P a— A Contact Phone No.: ( ) Make/Model of Monitoring System: Z41e 011 QTS /00/ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific equipment ins ected/serviced: Tank ID: 44 Tank ID: S u 5 C'a'in-Tank Gauging Probe. Model: /971*4 Erq-Tank Gauging Probe. Model: r4 41* U Annular Space or Vault Sensor. Model: rQ Annular Space or Vault Sensor. Model: ('F-iping Sump/Trench Sensor(s). Model: T`S Li-Piping Sump/Trench Sensor(s). Model: TS F”' Le J, ❑ Fill Sump Sensor(s). Model:_ ❑ Fill Sump Sensor(s). Model: li3'Mechanical Line Leak Detector. Model:, 7 Y Wr4echanical Line Leak Detector. Model: �l ❑ 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(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: - ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(s ezi equipment type and model in Section E on Pae 2). Dispenser ID: Y' A_ Dispenser ID: $ `4.f ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). �WG 5 ❑ Dispenser Containment Float(s)and Chain(s). y'Q rx Dispenser ID: Dispenser In: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(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): /� �/ A/ / ' fled Signature: Certification No.: O00�5` License.No.._9 / Page 1 of 3 03/01 Monitoring System Certification