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'QUALITY TESTING OF(INDF_RGRO UND 7ANKS'AT AFFORDABLE RATES' <br /> Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 <br /> (Teneral Information <br /> Facility Name: 'tkxU GGr � �J,���., Bldg. No.:_—. <br /> Site Address: 1City: _ (-A Zip:_1 c7,2'-� <br /> Facility Contact Person: Contact Contact Phone No.: ( a0�1 ) S' > - h 1 9 5 <br /> Make/Model of Monitoring System: !�4 Date of Testing/Servicing: <br /> _LL_/�/ <br /> B. Inventory of Equipment Tested/Certified <br /> Check the nEpropriate boxes to indicate ecific a ui rent inspected/serviced. <br /> F,�-� <br /> it ID: x'7-7 — 11 At t w Tank ID: I c, <br /> -Tank Gauging Probe. Model: /-JA G> / _Q'In-Tank Gauging Probe. Model: pYl4 61 / sfnnular Space or Vault Sensor. Model: f17c� nular Space or Vault Sensor. Model:iping Sump/Trench Sensor(s). Model: , Piping Sump/Trench Sensor(s). Model: -2 bars; <br /> ❑ Fill Sump Sensor(s). Model: '❑ Fill Sump Sensor(s). Model: <br /> 0 Mechanical Line Leak Detector. Model: 7'�GD 7 Mechanical Line Leak Detector. Model: P tV iz D <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). <br /> kTank ID: tF -7 5 � ✓r+ �y P�/�� Tank ED:In-Tank Gauging Probe. Model: 1�<4(� / ❑ In-Tank Gauging Probe. Model: j <br /> Annular Space or Vault Sensor. Model: `IZy ❑ Annular Space or Vault Sensor. Model: <br /> Piping Sump/Trench Sensor(s). Model: 7 lJ ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> rpther(s eci equipment a and model in Section E on Page 2). L3 Other(s eci equipment e'and model in Section E on Pae 2). <br /> enser ID: Dispenser ID:ispenser Containment Sensor(s). Model: Zy C3Dispenser Containment Sensor(s). Model: <br /> hear Valve(s). ElShear Valve(s).is enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). <br /> enserr ID: Q Dispenser ID: \ / <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: \f <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). \ <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: / Dispenser ID: % \ <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model:/ \ <br /> ❑ Shear Valve(s). / ❑ Shear Valve(s). j <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(,). \ <br /> w1f the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of monitoring equipment: For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): ❑ System set-up C3 Alarmmhhistery report <br /> Technician Name(print): Cin aIM 0 Si nature: <br /> g ` <br /> Certification No.: 3 License. N(.: <br /> Monitoring System-Certirication <br />