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Sep 04 08 01 : 27p Afforda Test (209) 744-0116 p. 2 A 4/aht 411 Hvelhh ellit", n.: oolc; 'heilyfor i(,), t, Ti., f: I,c'1 i This fiorni mu.,.t be used to document testin" and servicing of nionitorin, etillipinent. A sernu ate cerrification or report MLISt Ile prepared for each monitoring system control panel by tile techilician who pertbrnis the work. A copy of this form must be—pr'*<*)-,-,-i-cl-e'*c��-'t-(-, the tank system owner/operator. The ow-ner"operator must submit a copy of this form to the local agency regulating UST systems Within 30 lays of test date. A. General Information Facility Name: Ts L __ - Bid-- Nn.: Site Address: f City:_A�40A c4AIMI Zip: Facility Contact Pei-son: 620- 4-41A Contact Phone No.: Make/Model of rvlonitoring System: -/ / Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified ('11CA thea pXTUeriate boxeg to indicate specific e !Llpll I i tinqry )eCted/seiced: 2. C-11 - T kfD- 9? 0- X111-Tank Gauging Probe. &W— i ii-T�mlk Gauging Probe. Model: Model: - - z - X,Annular Space or Vault Sensor. Model: nnular Space or Vault Sensor. Model: �yPiping Sump/Trench Model:t, 710 e Iiping Sump/Trcnch Sensor(s). Model: 13 Fill SUMP SenS011S). Model: 0 fill Sump Sensor(s). Model: j (Mechanical Line Leak Detector. Model- A1 Mechanical Line Leak Detector. Model: Zzo 2oo Q Electronic Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model: Q Tank Overfill ii-figh-Level Sensor' Model: C3 Tank Overfill High-Level Sensor. Model: 0 0 Other(specify equipment tyQe and model in Section E on Page 2). C3 Other(specify e5tiiprlient type old model in Section E on Page 2). T. k ID: Tank ID: In-Tank Gauging Probe. Model: U In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: ) 0 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7-044;' U Piping Sump/Trench Sensor(s). Model: C3 Fill C Surrip,Sensor(s). Model: Q Fill Sump Sensor(s). Model: ] Mechanical Line Leak Detector. Model: El 70o 0 Mechanical Line Leak Detector. Model: Q - Electronic Line Leak Detector. Model: E? Electronic Line Leak Detector. Model: El T (3 Tank Overfill I High-Level Sensor. Model: C3 Tank Overfill/High-Level Sensor. Model: 0 C 13 Other(seecif equipment type and model in Section E on Paee 2). ciC.,equipment tXU and model in Section E on Pa Dispenser ID: Dispenser ID: -6 1 C3 Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: I ryShear Valve(s). ShearValve(s). Diseenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser I D: Dispenser ID: D1 A Ll Dispenser Containment Sensor(s). Model: C3 Dispenser Containment Sensor(s)._ Model: /,Shear Valve(s). 21 Shear Valve(s). XDispenser Containment Float(s)and Clinin(s)- 0 Dispenser Coliminnient Float(s)and Chain(s). Dispenser I D: Dispenser ID: i C3 1�6_ Q Dispenser Containment S s - Model: 0 Dispenser Containment Sensor(s). el: s C3 0 Shear Valve(s). 13 Shear Valve(s). d Chain(s).an DDispenser Containment Float(s)/n' E3 d Chain(s). Dis2enser Containment Floa P. *Iftbe facility C01113illS more tanks ordispensers,copy this form. Include information for eveil,tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was 1 nsiptetedfsert'siced PKi' 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 generating such reports,I have also attached a copy of the report;(Checif(111111alirply4v): D System U Alarm history report Technician Name(print): -DAVj,12 Signature: Certification No.: License.No.:_.,Izrx. Testing Company Name: —A "!,A TE57- PlioneNoj 20q 41112,rL Site Address: O Zr S ^r P49/,V" Date of Test i jig/Servici n 1 19 Alp Riloni(oriligs"'teall certification Pal-e I of3