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t � . f fia r 'QUALITYTES'TING OF UNDERGROUND 7ANKS'ATAFFORDABLERATES' i' Post Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Information �7 Facility Name: 4e4" J Bldg.No.: Site Address: 6/5/ �R(ef t/ City: �j—o c Tc��U Zip: 25' -Z-07 Facility Contact Person: ��1� Contact Phone No.: (z o 9 ) 1 ? - "4361) Make/Model of Monitoring System: �E�E ,120DT Tim—350 D�te of Testing/Servicing: B. Inventory of Equipment Tested/Certified 7 Check the appropriate boxes to indicates ecific equipment inspected/serviced. � OGS Ta ID: ging Probe. Model: /`�fl ( �, -Tlank Gauging Probe. Model: /KA-fsce or Vault Sensor. Model: ularSpace or Vault Sensor. Model.•/Trench Sensor(s). Model: t52 ng Sump/Trench Sensor(s). Model.- 35-2- FF umpensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ NJechanical Line Leak Detector. Model: ]ectronic Line Leak Detector. Model: OElectronic Line Leak Detector. Model: PL— —2) ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment type and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). Ta OC--7- Tank ID• Tank Gauging Probe. Model: /kt,A 6i t ❑ In-T k Gauging Probe. Model: ,FAn ular Space or Vault Sensor. Model: 3o 2— ❑ Ann __S r Space or Vault nsor. Model: iping Sump/Trench Sensor(s). Model: 315-Z ❑ Pipi g Sump/Trenc ensor(s . Model: ❑ Fill Sump Sensor(s). Model: ❑ F'I Sump Sensor(s . Model: ❑ echanical Line Leak Detector. Model: ❑ hanical Line ak Detec r. Mode. Electronic Line Leak Detector. Model: LL / ❑ -c= Lin eak Detect r. Mo el: ❑ Tank Overfill/High-Level Sensor. Model: ❑ ank Ove /High-Level ensor. odel: 1:1Other(s eci equipment ty e and model in Section E on Pae 2). Llther eci a ui ment e' model in Section E on Pa e 2). Dispenser ID: / `r Z Dispenser ID: 7 1( 8 VDispenser ispenser Containment Sensor(s). Model' ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). Shear Valve(s). is enser Containment Float(s)and Chain(s). is enser Containment Float(s)and Chain(s). ID: Disp user ID: ispenser Containment Sensor(s). Model: ❑ ispenser Con i ent Sen or(s). Mod hear Valve(s). ❑ hear s). Dispenser Containment Float(s)and Chain(s). ❑ ispenser Containment Flo and Chain(s). Dispenser ID: Dispenser ID: ❑ ispenser Containment Sensor(s). Model: ❑ ispenser Contai ensor( Model: _ hear Valve(s). ❑ Shear V is enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float ainW. *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 informatf (e.g. manufacturer ' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring q menta For any ment capable of generating such reports, I have also attached a copy of the report;(check all that apply): System set-up Alarm histery r ort Technician Name(print : t'� /V( Signatui:, / Certification No.: //f3 Licens Monitoring System Certification