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Sep 26 06 10: 59a Aff, is Test _ (2091 '44-0116 p. 2 f 'QUA.LITYTLSTING OF UNI-)(R(,IrUUND 7ANKEATAFFO/zD.91f1-Fl TLS, 4X6 2nd Street Galt,, C'A 95632 (209) 744-0.X12 FAX 744-0116 ' ` Genct"al Information � � � r^ Facility Name: ' (t eq r Bldg.No-: Site Address:_tel 15' ; 7�. E j, City: Facility Contact Person: jh Zip: 7 Contact Phone No.; z(Oq ) qg Z- 508 Lq Make/Madel of Monitoting System: V�eE-DEIZ T L -15Q Date of Testrn Servicin (d �� U B- Inventory of Equipment Tested/Certified Check the approLriutc bozos to indicate speellic equipment in ected/serviced: rT2T1,1 ED: DG Ta ID: G Tank Gauging Probe. Modcl. A- -Tank Gouging Probe. Model: nular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Modcl: ing Sump/Trench Scnsor(s)- Model: Pipine Sum / t Sump Sensor(s). Mvdcl: P B p Tkoneh Sensor(s). Model:❑ F'll Sump Sensnr(s). Model: chanical Linc Jwlc DCtector. lvlodol: echauical Line Leet Detector. Model: ctronic Line Lzak Dcttctor. Model: i7 Electronic bine Lcnk Drtoctor. Modalk overfin/It h-Level Sensor. Model: ❑ Tank Qvtxfill/Tlier(specify e ui ment'it and model in Section E on Page 2). ❑ Other oci o u vel Sensor. Model: Tank ID: �and in Section E on Pn ❑ In-Tank Gauging Probe. Model: Tank lb .S Ll Annular Sfax or Vault Sonsor. Model'. Giluging probe. Model: 11 piping Sump/Trench Sensor(s). Model: ❑ Annular SPace or Vault Sensor. Model: + -- ❑ Pill Sump Scnsor(s). Model: .Piping Sump/Trench Sensor(s). Model:. �p ❑ Mechanical Line Leak Deteetur• Model; C1 Fill Sump Sensor(s). Model. 4 Electronic Line Leak Aetcctor. Model: 'cal Line leak Dotector. Model: ❑ Tank Overfill/High-Level Sensor. Model., ❑ L?Icctronic Lino Leak Ikxi?or• Model: LJTnDis=ser ther s -fy ui ment tye and model in Section E on Pa> Cl Tank Overfill/High-levelSenRor. Modera 2). ❑ Other(s eci o ui ment ty a and model in Section E on Pae 2). cnscr m. 1 i �—. p ��ispcnscr Containment Senaor(s_) Model: ❑ Dispenser Containment Sensor(s). Model: car Valve(s). yghcar Valve(s).Containment Roads)and Chain(,). Dig enaor Containment noat(.')and Chain(s). Disperrver Ib: "f Dispenser ID LDisponxx Containmcot Sensor(s). Model: l�iapensrr Containment Senspr(s). Model: lvo(s). ❑ Shcar Valve(s). Containment Mcau.R)and Chain(s). ❑ Dis sContainment Floats)and Chain(s). - Dispenser ID: Conuiinmcnt Segsor(s). Madel ❑ Dispcnscr Containment Strosor(s)- Model: ve(s). ❑ Shcar Valve(R). Conwinment Ploat(a)and Chain(s). ❑ Dis 'Containment Floar(s)and Chain(s). •If the facility contains more Woks or dispenser;,copy this form Include infpmuttion for every tank and dispenser at the facility. C- CertiifiCation-I certify that the equipment identifled in this document was Inspected/serviced in aecordanec with the n=uf2ctnrvru1 guidWnes. Attached toi this Gerfficallon is information (e.g. manufacturers' checklists) oecessury to verify that this Information is correct and a Plot Plan showing the layout of tiwnitoring pmenC For nn e attached a copy of the report;(chock aft Uu t apply): y q�j eat capable of generating such reports,I have also A>r!) System set-up Alsrm history report Technician Name(print)" ! f i rCi 2CL Signature_: Ccrtificati on No.: _ Lie cwt.No.:�(�� 7�UT --- o7rc cxq- l�,*}� Monitoring System Certification