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to SCC ENY SEP 2 5 2006 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORD,4BL� �EW'f,�' 1WIENT HEALTHPERMIT `. RVICES 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 Ueneral Information p�/� �q i Facility Name: 1 1(x r- 1!C',(3�(�1 Bldg.No.: Site Address: ' � � kt�fF, Ci l=�l 4 %, (;l 1 ty:�S_ 'kL tT�1J Zip:._9,f1:;.,r 0 �7 Facility Contact Person: �2~two Contact Phone No.: .i' ) 95,.2-.q Make/Model of Monitoring System:g-e,CjP,(_ .r)r T( s -2�4:�n Date of Testing/Servicing: (2 / 1 L /QA2 B. Inventory of Equipment Tested/Certified Check the ro riate boxes to indicatespecific a ui meat ins ec.ed/se:riced: Tank ID: )�l o(-y Tank ID: C�c" 19 In-Tank Gauging Probe. Model: r"1 G'L In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: OZ Annular Space or Vault Sensor. Model:__ J Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PL.LT) NJ Electronic Line Leak Detector. Model:`21 4:2 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 1 ❑ 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: 0 7-V__ ID: .1f In-Tank Gauging Probe. Model: U..h 7 ❑ In-T uging Probe. Model: If'Annular Space or Vault Sensor. Model: ?/)'� ❑ Annular Sp or Vault Sensor. Model: ,A Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/ re Sensor(s). Mod ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). odel: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak D o . Model: lectronic Line Leak Detector. Model: E''�.•L.b ❑ Electronic Line etector. is ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Ove High-Level Sensor. Mode ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other eci a ui ment a and model in Section n�a a 2). Dispenser ID• 1 Dispenser ID: I, 4 y ' ❑ Dispenser Containment Sensor(s). Model' ❑ Dispenser Containment Sensor(s). Model: b Shear Valve(s). PCShear Valve(s). L"Dis enser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: ri 4 G� Dispenser ID:_ -z T ? Cl Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: Shear Vglve(s)_ [g Shear Valve(s). Dispenser Containment Float(s)and Chain(s). i bis enser Containment Float(s)and Chain(s). Dispi-efter-lB�;�.. �ense ID: ❑ Dispenser Containmee�i Sor( a,,.l { :` ❑ Dispenser o t Se vets}---tal�e�' ❑ Shear Valve(s). �.�^."' ""---�.. � ❑ Shear Valve(s . ❑Dis epr.C-'�fi narnent Floats)and Chain(s). - _ Cl ontainment Float(s)and Chain(s). *11'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 Pian showing the layout of monitoring qui menta For any equipment capable of geiierating such reports,I have also attached a'copy of the report;(check aff that apply): ystem set-up El }arm history report Technician Name(print): Z q/VF �1 i Mfy? Signature: �p Certification No.: /l D -7 License. No.:_T A .�j'Z l, '=j') 7 UT 077 H V 04q Monitoring System Certification