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for, bra--Tie <br /> 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' <br /> i` <br /> Post Office Box 36 Thornton Cal. 95686 <br /> .�J`� (209) 794-0102 FAX 794-0112 ;�.. <br /> General Information oo <br /> Facility Name: Lk��N t f�l` Bldg.No.: <br /> Site Address: 0 ?p Z. CU Iyi GG, City: Zip: <br /> Facility Contact Person: G Q L� Contact Phone No.: ( D'� <br /> Make/Model of Monitoring System:_ /��r•� TS J DDD Date of Testing/Servicing: P_�j/ 1 /o <br /> B. Inventory of Equipment Tested/Certified <br /> rCheckthe riate boxes to indicates ecific a ui ment ins ected/serviced: <br /> Tank ID: <br /> ging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ce or Vault Sensor. Model: ]`5 �� 5 ❑ Annular Space or Vault Sensor. Model: T =p/Trench Sensor(s). Model: TS(P U L S ❑ Piping Sump/Trench Sensor(s). Model:fSump Sensor(s). Model: S ❑ Fill Sump Sensor(s). Model: <br /> U Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Page 2). <br /> Tank ID• Tank ID• <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑'Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> CEJ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). <br /> Dispenser ID: Dispenser ID: "3/-,-/ <br /> ❑ Dispenser Containment Sensor(s). Model: 13Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID• Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: l t) S ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: U k-5 ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is <br /> correct and a Plot Plan showing the layout ofmonitoring equipment: For any equipment capable of generating such reports,I have also <br /> attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history report <br /> Technician Name(print):_ �;_1 I P t V�1 YY1 m[� Signature: <br /> Certification No.: License. No.: — <br /> t CC 5z.1! <br /> JUN 5 2006 <br /> ENVIROfVMEN, HEALTH . <br /> Monitoring System Certification PERMIT/SERVICES <br />