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J <br /> POB 36 26515 N. SACTO. BL. �C;Ontin000S Monitorin <br /> THORNTON, CA. 95686 —Q' <br /> x Device Certification <br /> 209 794-0102 800 524-9087 D <br /> [STET DATE 7 - l l <br /> 4:r <br /> SITE: <br /> OPERATOR a S Q5 + Station# OWNER kAA t,(Doo r 5 <br /> SIT`ADDRESS 2 o 1 ADDRESS <br /> PeoNE ( 2�y) - Dao s PHONE <br /> MAKE AND MODEL OF MONITORING SYSTEM AUK 7 UK AJ <br /> Contents of Tank g7 `)Z <br /> i <br /> Capacity of Tank / rvv- �aao <br /> Type of Product Line: (Gravity, Suction, Pressure). J e",6 I <br /> INDICATE LOCATION OF THE MONITORING SENSORS TESTED BY PLACING A YES OR NO INA PLICAE BOX: <br /> Annular Space Sensor Y f�j _____ <br /> Sump Sensor YE 5 y E S <br /> Dispenser Containment Sensor y Y lr�_ 5 <br /> Electronic Overfill/Level g� oo F.5 <br /> Electronic In-Line Leak Detector N o i.Yn <br /> Mechanical Line Leak Detector y�� yE_S <br /> In Tank Gauging Device y E 5 <br /> INDICATE THE FOLLOWING BY PLACING A YES OR NO IN APPLICABLE BOX: <br /> xJ o - N o <br /> Does the monitoring system have audible and visual alarms? V- V �5 V_ V6,5 <br /> Does the turbine automatically shut-down If the system detects <br /> a leak, fails to operate or is electronically disconnected? <br /> Is the monitoring system installed to prevent unauthorized tampering? s Y 4 S <br /> Is the monitoring system operable as per the manufacturers specifications? g s kq ES <br /> Which oontinuous monitoring devices initiate positive shut-down of the turbine? <br /> CERTIFIED TESTER'S IDS �� / QA-7 oZS' <br /> SIGNATURE OF CERTIFIED TECHNICIAN <br /> PRINTED NAME OF CERTIFIED TECHNICIAN 1 i wv <br />