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Enclosure #3 'QU.4LITYTES'TING OF(INDF_RGROUND 7ANKS'ATAFFORDABLERATES' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: of 106-lk GUr!� VtC,, -c, Bldg. No.: Site Address: 1331 5 HACA GY1 City: l., D(�_., Zip: 5.1'A Facility Contact Person: 1—Oco-� Contact Phone No.: (_ O� ) 3'�?>- Make/Model of Monitoring System: VCEC DIc(2- V O-1� 1 5- 3So-{ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecific equipment inspected/serviced. KTacID: �� — Kit ^J Tank ID:-Tank Gauging Probe. Model: NIAGr -Tank Gauging Probe. Model: /Y1 L1fJ1 aI nnular Space or Vault Sensor. Model: 7v nular Space or Vault Sensor. Model: ZO ping Sump/Trench Sensor(s). Model: 708 Piping Sump/Trench Sensor(s). Model: 20 ❑ )rill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: /Mechanical Line Leak Detector. Model: 7�L�Zyda ZrMechanical Line Leak Detector. Model:. X11 GD a ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: CJ 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 equipment a and model in Section E on Page 2). Tank ID: 0-7 S- %/i(c_ 5 y PSI C7 Tank ID: In-Tank Gauging Probe. Model: ?+ &r ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: `f ZO ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 70 ❑ 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: rDispenscr ther(s eci a ui ment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2): enser ID• �Z Dispenser ID: ispenser Containment Sensor(s). Model: lOgd ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). 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). \ ❑ 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 Ch n(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser aethe 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 a ui ent capable of generating such reports,I have also attached a copy of the report;(check all that apply): ,, stem set-up \larm history report Technician Name(print): Zan e IN 1 m M r) Signature: ~` Certification No.: `J License. Nr--�D� Monitoring System Certification