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n ' I • � i h - � � U U T 2006 E 'QU.ALITYTES'TING OF UNDERGROUND 7ANKS'ATAVORD NVIEiJNrWEr�r r!EALTh ' ` A13 � �ERVICES 416 2nrl Street Galt, CA 9. 632 (209) 744-0112 FAX 744-0116 General Information Facility Name: �12D - '/ / ' Bldg. No.: Site Address: �3 S. �lQ,t� !AV• City: Ld/)/ ZiP 9 2 O Facility Contact Person: ��;'JD`/ Contact Phone No.: ,x'9 ) 333- 6-530 (_ Make/Model of Monitoring System: �/cED1"►I ea,� /[rs—3 50 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates otitic a ui ment inspected/serviced: r (_ID.- P�7- 1 Tank ID: { F Tank Gauging Probe. Model:_�/j Gt ( .Lfln-Tank Gauging Probe. -77 pular Space or Vault Sensor. Model: Zt� Model:_/��6i Annular Space or Vault Sensor. Model: �Zp ing Sump/Trench Sensor(s). Model: 2,C8 Piping Sump/Trench Sensor(s). Model: fi1 Sump Sensor(,). Model: ❑ Fill Sum Sensors �G� Mechanical Line Leak Detector. Model: I`f's Z-CCC) p O' Model: ❑ Electronic Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specifzequipment a and model in Section E on Pa a 2). ❑ Other(specify a Iui menta and model in Section E on Pa e 2). Tank ID: _ � 7 - Tank ID: S ,��Ta,ffl,,Gauging Probe. Model: AGt / ❑ Tank Gau n Probe. L'i � g Model: Space or Vault Sensor. Model: t t 2 p 3Annular Space or Vault Sensor. Model:PipinSump/Trench Sensor(s). Model: ��yt3 Piping Sump/Trench Sensor( ) ModSensor(s). x ❑ Fill Sump Sensor(s). Model: ❑ Fill Sel: / 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: ❑ Other(s eci equipment a and model in Section Eon Page 2). ❑ Other(s eci a ui ment ty e and model in Section E on Pae 2). Di user ID: Dispenser ID: ,O Di penser Containment Sensor(s). Model: c��8 C1 Dispenser Containment Sensor(s). Model: hear Valve(s). El Shear Valve(s). ❑ Dis enser 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 • del; ❑ Shear Valve(s). ) Mo. • ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). C3Dispenser Containment Float(s)and Chain(,). Dispenser ID: Dispenser ID; C1Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s).__;t_ ❑ 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 gtdpment For any eq ' ment capable of generating such reports,I have also attached a'copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): 9A/,E �1 i rrj c, Signatu �• - --CertificationNo.: License.No.: 07 L 74 04-! - 1 l��