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tj ;3�0 E Ora 'I rP i -4 N,l P•a t �► �� P `t ® :l� V i. r J. 'QUALITY TESTING OF UNDERGROUND 7ANR S'AT AFFORDABLE RATES' 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 General Information l Facility Name: ��/�Yhd �i�JAG J Bldg. No.: Site Address: y y� �✓ C h�,eci r,�,.a t City: Zip: ?s Z D Facility Contact Person: r 6111 Contact Phone No.: �) Make/Model of Monitoring System: &it Ar/n VO( - 4A i b f 3f-) Date of Testing/Servicing: S 7/ OZ B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate 2ecific a ui ment ins ected/serviced: ID: 7 Tank ID: LIn-Tank Gauging Probe. Model• /�Y/4'�S / In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: 7�`4 5&Q — Z v 9 Annular Space or Vault Sensor. Model: ` "l G•J Piping Sump/Trench Sensor(s). Model: Ui w7 Ok Wiping Sump/Trench Sensor(s). Model: 7 ❑ Fill Sump Sensor(s). Model: ❑ ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ff 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(specify equipment a and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). Tank ID- Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank G-duging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: Cl Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FillSump 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 e ' equipment e.and model in Section E on Page 2). ❑ Other(s eci a ui ment type and model in Section E on Pae 2). L.. a Dispenser ID: ) Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: 7 dShear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Di penser ID: - / Dispenser ID: 0 Dispenser Containment Sensor(s). Model: Z�'-� �le7�Dispenser Containment Sensor(s). Model: 7-D ;d Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)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'GerWlcation is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout Of -monitoring equipment: For any equipment 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): Lille _ 1\A�N M rn 0 Signature: Certification No.: License. No.: UFO �9 — )L13 _ I CC # 52-LACI 115 - u i Monitoring System Certification