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AFFORDA-TEST 12097940112 P. =i4 A f farbat,- Te,$f VUA,W1T 7FS71NC OP (1NPARGROIW) 7ANKNAy'APPORDAllL RATEV Post Office ,Sox 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-•0112 '} "General information Facility Name: �� C r y �dI �P !? h d �j - --- _ _ H 11 No.: _ g;. f Site Address: .1 �)�J I_ .� K ` �. �:... _ .._-..(ity:! of-^- - . --- Zip: r_..t1:1j CJ....4..... r..........----.I"-:'C.•'- ( �.merl 1-11rnet' 1110". 1 I Make/Model of MnniUlring Syalcm:. ,tle"AlAwl /-j-5 $ r 1 role 114 Testillp/Servichig: B. inventory of Es<itTipnlrn! '1'e9tedl('ertillt•rl Berk the annronrlate haarem In lemilrate..b.Arl .m.1 -i Tank 1D: tit _� '_-_,_.... wl��at_mr 'Tank I1): P U In -Tank Gauging Probe. Model: _ U In -Tank Gauging Probe. Mmlel: _ „- � - - U Annular Space or Vault Sensor, Model: U Annular Space or Vault Sensor. Model: q Piping Sump /Trrnch Sensor(s). Model, U Piping Sump/ Tronch Sonftor(n). Model: _='-,Z�?Y U hili Surnp Senet/t(a), ModrL U 11111 Sump seapor(s). Modtl;`w- !'. o- L/..._ fl._..1- \r_. __..... Ll Mectronic Line Leak Detector. 1-....1— __ I___ Model: , _ _ 4 1,-J I.JI i.w k I.......... r.. /...na.l. U Flectmitle Line Leak Ntector. Modol: U Tank Overfill / High -Level Sensor. Modei: C] Tank Overfill / high -Level Sensor. Model: _ ❑ Other (mccify equipment !ZU and model in Section E on Page 2). U Other (specify ui ent type and modal in &=do� n 8 on PzU2L_ Tsnk ID: It Tank iD:._ . !2 14 � -- --- — O in -Tank Gauging Probe. .r U In -Tank Gauging Probe. Model: _.� © Annular Space or Vault Sensor. Model: _ U Annular Space or Vault Sensor, Madel: _ d Piping Sump /Trench Seaports). Motel: _ _9 �(• = _7�'` L) piping Sump I Trench Sensm(s). Model,� 14 � L U "it Sunup Senaor(s), Mfxlet: ,--- _-..._. ...-.._ _-.-- U Ftii Sump Sensor(s), Model: U Mechanical Line Leak Detector. Model: � �- U Mechanical Line t..eak Deector, Modell: 0 Electronic Une Utak Detector. Madel: _-_. U Plectronic Line Leak Dewitor. Model: U Tank Overfill / Ifigh-Level Senacv. Model __.._ _ _ _ U Tank Overfill / High -levet Seneor. Mo&l;: 0 Other (opecify equipment tXpS and inodol tosd a axil ui nr t aruAl rrarrnl le R,.. rl.,.. R /r► l I M At.perrler lri: _ L -. -- --- -.- lAgwtner It): U Dittper11"CnntainInent Sell 1118). M/aicl: 7 y3 8th Od� U IIiR)renaer('untsinnirltt 5entlnu(s), MINio gQ `tet? a� ❑ Shear Valve(e). ��9� U Shear Valve(s). U Dia ser Containment Floats and Cllain(s). Ll Dispenser Contalnrnent Float(s and Chainl�n��r � 111apertser 1D ) Dispenser ID: Y UDispenser Containment Sensor(a). Modcl:_12tli *1�-ao QDiApensaContainment sensor(s). Model:_�g�Yg°tp"��Cr�ry U Shear Valve(s). ❑ Shear Valve(s). U DispeawContainwitt Float a and Chain(s), U DispenwContainm alt Flont s shirt ChainftiL �f..�+..-...._......,...l,;1 .:,,.,.,�,�! ....,...... . � v -_ ......, � ��►d�rFa�S.,uruarnrnenr at'nso ts). � Morel � �' ,. , v i �.-,.'""�:. ❑ Shear Valve(s). C] Shear Valve(s). ❑Di ser Containrnent Floats and Chain(s), U Dia ser Containment Floats And Chain s'. -Ir UPC raearay conrnms more tanKE or otspensers, copy tnlS Iortn. Include fnfortnation for every tank and dispenser at The facility. C. Certification - I certify that the egalpnient identitled tit this document was Inapec("Werviced In mocetrdnnee' ith the farwufiaetaunlrk0 galdelinim Attnrhecl to this Ctrtificstion is Inforl-Ifon (e.g. rnanttracturers' cheekiista) necemiry to Ytrtlry lluit line Ido. r oMWn It correct and a Flot Plan showing the layout of monitnrioR equipment. For any etlulpn"t capable of gerrerstir.ig lrgc'h reports, )I ti yj ruins attached It copy of the re tt)�(chec all raR> n��lv)r l7 Syntem set -tip l,-1 rt h to ep ort \ / - -- 'Technician Name (print). 7_�R�L _ --Sigmetole: a«' ��'r Certifr.alinnNn.:_(�_�f„�Q(.eO Testing Cumpnny Nnmc: �Z�S2_rl a .-_.._... - - Phone No j_,.-)--- t'nRt 1 of 1 QM� Monlloring System ('erfmcnaorr