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Pr uv vn r i vP s- V � i � P4 P Df t d# ►d ��`C A � �i� OCT 2 200 t )UALI YT G OF UNDERGROUND TANKS'ATAFFORDA 4TES' EMAR(AMEN HE �� 416 2�MYTPt"CESGalt, CA 95632 (209) 744-0112 KFS 77 RVI('tS 44 0116 ti ' 3 General Information � � ��T �XKU Facility Name: L Bldg.No.:. Site Address: 1�4 (5- EL J)pQAT'�Q City: Zip: 'J Facility Contact Person: 4IJt)q Contact Phone No.: L�--D_l ) 9�2,- s03 Make/Model of Monitoring System:_Ve1EDEIZ 1?bOT `r'L5- SF,� Date of Testing/Servicing: /2e/D(Q B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ins ected/serviced: Ta k ID: 8 OG Ta ID: n-Tank Gauging Probe. Model: In-Tank Gauging Probe. D.^Iodel: M Q,C nular Space or Vault Sensor. Model_ �Zd Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: $ ET-Piping Sump/Trench Sensor(s). Model- Zp g ❑ 11 Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ❑ 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 Page 2). ❑ Other(specifya ui meill t 1,11, a and model in Section E on Pae 2). iTank ID: Tank ID: T)(Es E t_ ❑ In-Tank Gauging Probe. Model: ZIn-Tank Gauging Probe. Model: M11 { ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 1 C3 Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: © ll Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C1 Mechanical Line Leak Detector. Model: echanical Line Leak Detector. Model: C] Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(s ecify equipment ty e and model in Section E on Pae 2). Dispenser ID: 14 Z_ Dispenser ID:_ t7 -Ii 2?:::, ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ear Valve(s). Dispenser Containment Float(s)and Chain(s). ,tom Dis enser Containment Float(s)and Chain(s). Dispenser ID: '34-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model. Shear Valve(s). ❑ Shear Valve(s). Lspenser is enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). enser ID: ��"f 6 Dispenser ID: ,WSispenser Containment Sensor(s). Modeh ❑ Dispenser Containment Sensor(s). Model: Sh,ar Valve(s). ❑ Shear Valve(s). Containment Floats)and Chain(s). ❑ 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) neressary to verify that this information is correct and a Plot Plan showing the layout of monitoring a 'pment- For any eq . ent capable of generating such reports,I have also attached a'copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): Z9NF &I n Signature: Certification No.: c�5 License. No.:-= I $ ,5_2_1,3 3 2,2 UT CY7 L Monitoring System Certification