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'QUALITYTES'TING OF UNDERGROUND 7ANKS'ATAfFORDABLER4TES' 416 2nd Street General Information City: FAX 744-0116 Bldg. No.:� 4 A NTEC Azip: 5 3 t Phone No.: LZ'5�) 23 I — 3 -2-5 2 -- Date Date of Testing/Servicing: Facility Contact Person. Contac Make/Model of Monitoring System: uJT B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate s eeific equipment inspected/service Taro ID: ,1 In -Tank Gauging Probe. Model: X�nular Space or Vault Sensor. Model: mg Sump / Trench Sensor(s). Model: �p 8 A 5M Sump Sensor(s). Model: )21"Mechanical Line Leak Detector. Model:Zppd ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Paee 2)_ Tagk ID: " 1 DL , �-Tanit Gauging Probe. Model: M p.6t pular Space or Vault Sensor. Model: ,ng Sump /Trench Sensor(s). _ Model: a �1 Sump Sensor(s). Model: _ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) ID: I a — �-- ❑ Other (specify equipment type and model in Section Eon �D,is�er Pt A"penser Containment Sensor(s). Model: a SCJ Shear Valve(s). Model: ❑ Dispenser Containment Float(s) and Chain(s). Dis user ID: _ C-5 -I— `f spenser Containment Sensor(s). Model: _ 1d Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). y Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Leve] Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Tank ID- ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: —� ❑ Electronic Line Leak Detector. Model: Cl Tank Overfill / High -Level Sensor. Model: ❑Other (sped equipment type and model in Section E on 1 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment F1oat(s) and Chain(s) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dis enser C 2). 2). ontainment 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) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoringpmenL For any a ment capahle 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): _Z�ilV 1 i 4� Signature: �— Certification No.: License. No.: 077 L �P 04q -1 Monitoring System Certification