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Jan 03 07 04:18p Rf�'^rda Test (20x) 744-0116 p.2 1 � IL'QUr] LI7Y TE, N(r "17Ol% (INJ� j R(rRO (INU 7i1 NKS' A7�r1 r-T'Orrr�ilnl G r1,!A TESD I ,Post Office Box 36 Thornton, Cc. 95686 General Information lity Name: Site Address: Facility Contact Person: Make/Model of Monitoring System: (_ B. Inventory of Equipment Tested/Certified � Check the approgriaie boxes to Indicate upecrfic equipment ins ec.tad/aervlcc F:�FP'1111 ID: G� Tank Gouging Probe. Model: ,Annular SpAco or Vault Sensor. Model; _gyp ingSump / Trench Senvgr(s). Model: Sump Scasor(s). Model: Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify u; meet type and model in Section E on Page 2)_ Tank rD: 7?CT ❑ in -Tank Gauging Probe. Model: pular Spate or Vault Sensor. Model: 6&W Piping Sump / Trench Sensor(s). Model. ❑ Fill Sump Sensor(a), Model: vicchanical Linc Leak Detector. Model: *4-1 V ❑ Electronic Line Lcak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 13 Other fs ecify equipment type.and model in Section E on Pa m 2). Dispenacr TD• I ❑ ispenser Containment Sonsor(s). Mndel: hcar ValVe(s)• Dis eraser Crmtainment Float(s) and Chains . Dispenser ID: ❑,Disncnser Containment Sensor(s). Model: hc:,,t Valve(s). ZI Dispenser Containment Flont(s) and Chain(s). Dispenser rD: ❑,Disponser Containment Sensor(s), Model: U hear Valve(s). Ds enser Containment Floats) and Chain(s). wlf the facility contains more tanks or dispenses, copy this form, Include it C. (209) 794-010.2 FAX 794-0112 w Bldg. No.: City: LoD � Zip:Ae3 a Contact Phone No,: (_2et) $:641 ^ Date of Testing/Servicing: -L/ Q �-/thaw.. � Tank ID: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Z -Piping Sump / Trench Sensor(s), Model: - ❑- Fill Sump Sensor(s). 'Mechanical Model: Line Leak Detector. Model: L -p ❑ Electronic Line Leak Detector. Model: ❑ Tank ovwfill / A]gh-r.evcl Sensor. Modcl: ❑ Other (specify ui ment type and model in Section E on pare 2). Tank ID: - ❑ -Tank Gauging Probe. �Aftnular Space or Vault Sensor, JXPiping Sump / Trench Scnsor(s). ❑ Ff11 Sump Sensor(s). .WM-chanical Line Leak Detector. Cl Electronic Linc Leak Detector. ❑ Tank Overfill t Nigh -Level Scnsor, Cl Othcr (specify ui ment type and r Dispewer M- j 9❑ pispenser Containment Sensor(a). Shear Valve(s). W&npenser Containment Float(s) and Dispenser ID: q 4 ❑gispenscr Containment Scnsor(s) Shear Valve(s), Model: Model: Model: Mede]: Modc]:�— Model• Model: lode] in Section E on Paee 21 Model: Model: and Chain(s). Dispenser ID: '.iAIeZ,f , `7 >� C7 pispcnser Containment Sensor(s), Model: hear Valve(s). Dispenser Containment Float(s) And Chain(s)_ _ formation for every tank and dispenser at the facility, Certirl cation -I certify than the equipaw at identMi'd in this documt•nt was inspected/serviced in necord anee with the manufncturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this infurmnti re is correct and a Plot Plan showing the layout of monitoring equipment: 1' or any equipment capable of generating such re ort_, I have Also attached ti copy of the report; (check all that apply): Ll Systelt set-uu © Al history report MoNF— Technician Name (print). \ Signa rr.: _ Certification No.: J 1,��- License, 7 Monitoring Systchn^CertifiCatinn