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• f forbal-W 'QUAL77)' 7'F_.S'7/NG OF' I INI )F.RCiROUNI) 7'ANK,S'AT AFFORDA Post Office Box 36 Thornton, Ca. PF 'General Information Facility Name: Site Address: -- Facility Contact Person: __ �� t'e �✓/J Make/Model cif Monitoring System de{ 7.�5 -✓�� II. Inventory of N,quipnlenl 'I'estt�tl/l'erlihit tl FEB 1 8 2003 (209) 794-0102 JIVIWI NT HEAL_ 65 ITFAERVICF� EAX 794-0112 -- - — - - -- — Bldg. No.: Cily' ---- -- -- ---- ---- Tip' L Contact Phone No. __-- Comaof II-sling/Servicing: - - - - - - Tank ID: t �G c; (i (— - 'Tank ID: U In-Tnok Gauging Pmhe. Model: O in -Tank Gauging Probe. model: _ _ ❑ Annular Space or Vault SenSnr. Model: - _ U Annular Space or Vault Sensor. Model: ❑ Piping Sump /Trench Sensor(s). Model: U Piping Sump / Trench Sensor(. Model: ❑ Fill Sump Semor(s). MndeL U fill Sung, Srusm(,9). MIMIC[: U Mechanical Line I enk t mec-Um. Model:. _ . U Mechanical Line I .enk Defector. Model: O Electronic Line Leak Detector. Model: __- _ - -- U Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: _ U "Tank Overfill / Iligh-bevel Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). ❑ Other (specify ui ment type and model in Section E on Page 2). Tank ID: ,,) I I !------.--_-- Tank It)- L, !n U In -Tank Gnuging Probe. Model: ❑ In -Tank Gauging Probe. Model _ ___ O Annular Space or Vault Sensor. Model: _ U Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: _� cj �.(- `?Ci _ ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ . - U Fill Sump Se.nsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ------ .__. - ___._ U Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _-_ _ ❑ Electronic Line leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Morcel _ _ U 'Lank Overfill / Iligh-bevel Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2). U Oliver (specify ui ment type and model in Section E on Palte 2). Dlrpemer ID: _ -_-- __-_ Dispenser ID: _-----_--- �� U Dispeniter Containment grn4ol(m). Model d7L� hU U Dispenser ('nntninment Sennot(s), Model:C3 Shear Shear Valve(s). U Slienr Valve(s). ❑ Dispenser Containment Floats and Chain(s). U Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: "Y ❑ Dispenser Containment Sensor(s). Model: t- ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chaire(s). U Dispenser Containment Floats and Chain(s). Dispenser ID: _-____-- Dispenser ID: ❑ Dispenser Containment Sensor(s), Model ? `' D U Dispenser Containment Sensor(s). Model: 7 9=1 3 7'0 O Shear Valve(s). U Shear Valve(s). LIDispenser Containment Floats and Chain(s). O Dispenser Containment Floats and Chain(s). off the facility contains more tanks or dispensers, copy this (inm. Include informtntion for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identified hr fllis dncumeut wag liespecterl/serviced In accordance with the nMnufacturers' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verlry that thb in(otmdim Is correct and a Plot Plan showing the layout of rimniforimg equItinlent. For any equipment capable of generating such reports, I have abo attached a copy of the report; (check all that applv): U SyRlem Ret -up ❑ (arm history report Technician Name (print): , rt +i_'_=_- Certification No,: (?� f (� -C�.Cv O Jjj'_ 11cemw No. -/ � //H ..-•----_-.. Testing Company Name:� rs^_V ._.. _--- Phone Noj---- ----_� 1'nRc I of 1 03101 Moniforing System Certification