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iNf forba--Z 't <br /> t 'QUALITY TESTING OF UNDERGROUND TANKSATAFFORDABLERATES' <br /> 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 4... ' <br /> ' Ueneral Information J t L �' I ���� �XKo . <br /> Facility Name: Bldg.No.:__ <br /> Site Address: U, "Dc&A D �, City: P: 5 <br /> n. � <br /> Facility Contact Person: 4Mt>`7 Contact Phone No.: z( D� ) q6?.- 5C)34 <br /> Make/Model of Monitoring System: VeEt)E(2— EO07 TLS- SSQ Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate gedfic equipment ins ected/serviced: <br /> Tank ID: g 7 OG Kn <br /> ID: ©� <br /> -Tank Gauging Probe. Model: Tank Gauging Probe. Model: <br /> pular Space or Vault Sensor. Model: Zo ular Space or Vault Sensor. Model: o <br /> Piping Sump/Trench Sensor(s). Model: 7 94l? ET Piping Sump/Trench Sensor(s). Model: 717$ <br /> V❑ 'll Sump Sensor(s). Model: C3 Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: ,Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Page 2). El Other(specify equipment a and model in Section E on Pae 2). <br /> Tank ID: Tank ID: D(ES E L— <br /> C] <br /> ❑ In-Tank Gauging Probe. Model: XrIn-Tank Gauging Probe. Model: Klk.t <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: ,Piping Sump/Trench Sensor(s). Model: ' g <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: echanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model:-7 ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(speciL equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page <br /> Dispenser ID: 1 z— Dispenser ID: `7 $ S <br /> Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model- <br /> hear Valve(s). ear Valve(s). <br /> k0z�DIispenser <br /> Containment Float(s)and Chain(s). 1,ff Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 34-4 Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(,). ❑ Shear Valve(s). <br /> Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: (o Dispenser ID: <br /> LP`ispenser <br /> ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> he Valve(s). ElShear Valve(s). <br /> Containment Float(s)and Chain(s). 1 ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. <br /> C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. AWiched to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout ofmonitoring e, 'pmenk For any eq . ent capable of generating such reports,I have also <br /> attached a'copy of the report;(check all that apply); System set-up Alarm history report <br /> Technician Name(print): / --- -Signature: <br /> FS <br /> Certification No.: FS License.No.:T 4 5--Z6 6 13 2,9 UT <br /> AUG 0 8 2006 OWL <br /> ENVIRONNIEtj HEALTH <br /> PERMIT/SERVICES -' <br /> Monitoring System Certification J J6 �7 <br />