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JUN 14 ENVIRONMENi QUALITYTESTING OF UNDERGROUND 7ANKSATAFFORDABLERAT r Post Office Box 36 FAX 794-0112 V'General Information ' Y Facility Name: [ 5 �.s�i="'"��[ �'� P�" ' �-+ 1 Bldg. Nc Site Address: %D I 4° rT`�'r �flr�,r City: '�%7/' �1 e ,�I'/ Zip: Facility Contact Person: Contact Phone No.: ( Make/Model of Monitoring System: _7W C, 001 S /�� r � Date of Testing/Servicing: �d /;L/a-V B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate specific equipment inspected/serviced: Tank ID: u — O Tank ID: 21n -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: JW Grc. pular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 56Q I i a' K 3 Piping Sump / Trench Sensor(s). Model: t 12 14 k. $ ❑ Piping Sump / Trench Sensor(s). Model: TS if L- 0 O F1j,.Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 3,14echanical Line Leak Detector. Model: ,, .k / ❑ 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 (specify equipment a and model in Section E on Page 2). ❑ Other (specify ui ment 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment a and model in Section E on Page 2). ❑ Other (specifX equipment and model in Section E on Pa,e 2). Dispenser ID: Dispenser ID: 3 it 11� ❑ Dispenser Containment Sensor(s). Model: u ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float( and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: u ❑ 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 ofmonitoring 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): Ae A) I-V jen Signature: („ n 4' Certification No.: License. No.: Page 1 of 3 03/01 Monitoring Svstem Certification