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72 14 1 ' 1 _ �, b_ .. II _ N' i.►'H_ . 'a 1 f forba-Z� I r . l � 'QUALITY TEWYAIG OF UNDERGROUND 7ANKSATAFFOIZD,"IBLE RATES' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 GeneralInformation q ,J Facility Name: r �k (. 1 ( ��i Bldg.No.: Site Address: I73 n 1 M �+ ;tet . City: �% '� t A Zip: Facility Contact Person: i� /t2 !)'f Contact Phone No.: .J d� Make/Model of Monitoring System: S Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the approgriate boxes to indicatespecific equipment inspected/serviced. Tank ID: �I°L u r /0 Tank ID: ❑ II -Tank Gauging Probe. Model: r1_2 19-f 42 / ank Gauging Probe. Model: IYl 4Q C3'Annular Space or Vault Sensor. Model: 7e'1!3J1 0�-,41 P o LrAnnular Space or Vault Sensor. Model: V �4-;2-p (3 ,ping Sump/Trench Sensor(s). Model:-70-,4,!P50-2�5.�- U`Piping Sump/Trench Sensor(s). Model: Z 0<R_ ❑ 1511 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Cl 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 t e and model in Section E on Page 2). ❑ Other(specify equipment e and model in Section E on Page 2). Tank ID: Tank ID: j;Tank Gauging Probe. Model: {HT1 GH /C C) In-TankGauging Probe. Model: anular Space or Vault Sensor. Model: ;i Annular Space or Vault Sensor. Model: `' n Piping Sump/Trench Sensor(s). Model: :W Piping Sump/Trench Sensor(s). Model: -- r ❑ Fil Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: )T _, ❑ 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 e ui ment e and model in Section E on Page 2). ❑ Other(s2ecify equipment a and model in Section E on Pae 2), Dispenser ID: `Z%i:� (o Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ?Q L t D ❑ 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). ❑ 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 of monitoring equipment. For any equipment capable of;venerating such reports,I have also attached a copy of the report;(check aU that apply): ❑System set-up ❑Alarm histery report J ( , 'jj> Technician Name(print): 0 Signatur.: Certification No.: License. No.: ATG Monitor Fom Monitoring System Certification