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#fnrdtt- (`�e�i 'QUALITY TES'TING OF UNDERGROUND 7ANKS'ATAFFORD,ABLERATES' V Post Office Box 36 Thornton, Car'. 95686 (209) 794-0102 FAX 794-0112 General Information/� lity Name: FL Q. �, COY lit/0 1/(D nl Site Address: 6 `17-1 CA P i TA t- iT City: LO D / Facility Contact Person: 4aFq Contact Phone No.: (—L0-1 M k /M d 1 f M fF DEIN Dol Bldg. No.: Zip: ?5',7-V z 9 1 334- o9-15- a e o e o onttortng System: R TLS - 3 So Date of Testing/Servicing: $/ 8/ o S B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific a ui ment ins ect d ID: 9/ DGS Ta kED 87 vr)AS-TkV.n-Tank Gauging Probe. Space or Vault Sensor. Model A !int Model: Tank Gauging Probe. Model: r-4 A, e-1nnular [;n Annular Space or Vault Sensor. Model:iping Sump / Trench Sensor(s). Sump Sensor(s). Model: 2�8 iping Sump / Trench Sensor(s). Model:'ll Model: O (g' I Sump Sensor(s). Model:echanical Line Leak Detector. ❑ Model: FLiO,Fr . (} Mechanical Line Leak Detector. Model: F 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 a and model in Section E on Page 2). Ta kID: Di5S5 Taa 8-7-5( AVE In -Tank Gauging Probe. Model: W I 4 In -Tank Gauging Probe. Model: �t Annular Space or Vault Sensor. Model: V-. 7 Annular Space or Vault Sensor. Model: Faping Sump / Trench Sensor(s). ill Sump Sensor(s). Model: 2 ❑"Piping Sump / Trench Sensor(s). Model: ZC3 Mechanical Line Leak Detector. Model: pF3 Model: Q2 COO -!.Fill Sump Sensor(s). Model: 7 L3 Electronic Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Jr� PE711� ❑ Tank Overfill / High -Level Sensor. Model: ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. Model: Model: Other (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). spenser ID: / '� Z Dispenser ID: °� 8 Dispenser Containment Sensor(.). Shear Valve(s). Model: c `�, ispenser Containment Sensor(s). hear Valve(s). Model: 2 Dis enser Containment Hoat(s) and Chain(s). [Dispenser ❑ Dis enser Containment Floats) and Chain(s). ID: 310 Containment Sensor(.). Shear Model:_ 7 �'�7 Dis enser ID:Dispenser � Dispenser Containment Sensor(s). Model•Lj Valve(s). Shear Valve(s).Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 f ,0Dispenser Containment Sensor(s). Model: 0% Dis euser ID: O" Shear Valve(s). Dispenser Containment Sensor(s). Mosel: -- ❑Dis enser Containment Float(s) and Chain(s). Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(.). n me racnnry 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 eq 'ilment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up / Alarm histerV report Technician Name (print): Signatw Certification No.: �8� License N . _ 04 106 Monitoring System Certification