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f forba.-W 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' Post Office Box 36 Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the aparoariate boxes to indicate specific equipment insnectPd/aPrvirPa- FAX 794-0112 n Bldg. No.: C�- 07 Zip: ;2 Z2 Date of Testing/Servicing: 'e- ) L11_46_/P_f' Tank ID: �l 5�� - Tank ID:7 f3T-Tank Gauging Probe. Model: 0'& -Tank Gauging Probe. Model: *Wa Q / R -Annular Space or Vault Sensor. Model: 2i�It46 ' �©7 CI -Annular Space or Vault Sensor. Model:'74-4�S & -"-gid 5 �h�.i-`P ing Sump / Trench Sensor(s). Model: % 9 p -'l 3��J -; 5'- U -Piping Sump / Trench Sensor(s). Model: §ill Sump Sensor(s). Model: ' ,2/ _ C3 -Fill -Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 5_) �"AZ7 2-ITe-chanical Line Leak Detector. Model: .o ❑ 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 t e and model in Section E on Page 2). Tank ID: ,R 7 S AZ.lr v e Tank ID: A57/'o--s Cl -in -Tank Gauging Probe. —e/ Model: 0 In -Tank Gauging Probe. Model: EY Annular Space or Vault Sensor. Model: 3'Annular Space or Vault Sensor. Model: /4 0 ? l� iping Sump / Trench Sensor(s). Model: 2(9'K- 13'Viping Sump / Trench Sensor(s). Model: J lw 1037 14'11 Sump Sensor(s). Model: ate? ®Fit Sump Sensor(s). Model: =0 P -- Mechanical Line Leak Detector. Model: '5J�P AI/ C]'Aechanical Line Leak Detector. Model: ,7-,oV ❑ 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 a ui ment a and model in Section E on Pae 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Dispenser ID: DL _ Dispenser ID: _3 �t, a h ❑ Dispenser Containment Sensor(s). Model: of U ❑ Dispenser Containment Sensor(s). Model: a0 iC' ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 4, Dispenser ID: ❑Dispenser Containment Sensor(s). Model: tel) ❑ 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: `' )1'-- /0 Dispenser ID: / / ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 2 lJ ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). 1 ❑ 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 all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): �' �l !'yll� Signatui:;: �7 Certification No.: &067 License, No.. 3 Page 1 of 3 03/01 Monitoring System Certification