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Iforba—T9cpL <br /> 'QUALITYTESTING OF UNDERGROUND TANKS•ATAFFORD4 ��N�E' 2006 <br /> W'1HGf HENT HEALTH <br /> 416 2nd Street Galt, CA 93632 (209) 744-0112 TEW4 -W16 <br /> u <br /> _ ' General Info/rmatiorn/ <br /> Facility Name: �� D /� �<) 1 ��11 ' Bldg.No.: <br /> Site Address: .� �J c y 1.j 17 City: !': r Zip: <br /> Facility Contact Person: C✓ Ll U ice"' '17 Contact Phone No.: (_) <br /> Make/Model of Monitoring System: T TL7 — /0 Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Chedr the nnnrnnrinte hovel to indicate a e—Mic n - -_ <br /> u Cl'i'7l:CLL' <br /> F <br /> : (� Tank ID: <br /> ank Gauging Probe. Model• ❑ In-Tank Gauging Probe. Model: <br /> ular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ng Sump/Trench Sensor(s). Model: ❑ 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 /> ❑ El ctronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> E'Tank Overfill/High-Level Sensor. Model:_L S —/ ❑ 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 Pae 2). <br /> Tank ID: Tank ID• <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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 /> ❑ Other(s eci equipment a and model in Section E on Pae 2). ❑ Other(s eci a ui ment ty e and model in Section E on Pae 2). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <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 /> El 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). <br /> ❑Dis enser Containment Fioat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> "If 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'(✓,ertification 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 ag that apply): ❑System set-up ❑Alarm history report <br /> r• 1 �\ <br /> Technician Namerint : I yINSignature: t y' <br /> (P ) LY1Y12 <br /> Certification No.: f7✓ License. No.: OjEj — Cj rl — (d3 <br /> CC 62A9 - Ll <br /> Monitoring System Certification <br />