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64 'QUALITY TESTING OF UNI)F_RGROUND 7ANKSAT AFFORDABLE RATES' i Post �Q,Q�ice Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 t !!General InfforCrmation , , Facility Name: J ` ` ✓ ��N0t 6)10 e_le r ycr Bldg. No.: Site Address: "-2 0 11��-,1'-- Cha r )-.1 City: "Jm A--� f -Mo Zip: g.5�0 Facility Contact Person: K ot- I _ _ _ Contact Phone No.: D-X06— Make/Model of Monitoring System: N do 0DOk'/=1 Date of Testing/Servicing: 7 B. Inventory of Equipment Tested/Cert ilied Check the appropriate boxes to indicate specific equipment inspected/serviced+_: 7_,i4 K !-- Tank ID: 5140 _ Tank ID: _ R V 1. O InJank Gauging Probe. Model: ❑ In-T'uak Gauging i'robc. Model: UAnnular Space or Yeett9ensvr. Model: ❑ A Model: lis ping Sump/Treneh-8etrsvr(s). Model:Z`P t-t 7r GrPiping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model: Urm—echanical Line Leak Detector. Model: 01Clechnnical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/I ligh-Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). 3-Miear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). O Dispenser Containment I'loat(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: _ ❑ In-Tank Gauging Probe. Model: j ❑ In-Teak Gauging Probe. Model: O Annular Space or V,#,ult Sensor. Model: L3Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench'Serlsor(s). Model:,' ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). ❑ Fill Sump Sensor(s). _-Model: ❑ Mechanical Line Leak Detector. 'Ntedel; ❑ Mechanical Line Leak Detector: Modek_ ❑ Electronic Line Leak Detec(or:" Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill/High-L el Sensor. Model:_ ❑ 'rank Overfill/I ligh-tLevel Sensor. Model: O Dispenser ContainmEnt Sensor(s). Model: ❑ Dispenser Conlainmcni Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floal(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). C. Certification - I certify that the equipment iden(ilicd in (his document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this C'er(ification 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): ,�� Signature: Certification No.: ' ' h?77"? License No • Phone No.: ��041 )79'`/— D/OZ