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t s 1 _ 1Z 9 R=I T4 9 v t Aft f fX D GREC EWI V QUALITYTESTING OF UNDERGROUND TANKSATAFFORDABLERATES' JAN 2 6 2004 Post Office Box 36 Thornton, Ccs 95686 (209) 794-0102E ��9E4��112 HEALTH PERMIT/SERVICES General Info ation Facility Name: isl A ` r„ t('p Bldg.No.: Site Address: / ' o � ` tA)p1~ ac _ Roe � City:�C - Zip: u9 Facility Contact Person: Contact Phone No.:O Make/Model of Monitoring System: H"/ Y " (-QW`( Date of Testing/Servicing: B. Inventory of Equipment TesteNCertified Check the a ro nate boxes to indicate ecific a ui ment ins cted/serviced: Tank ID: A " - Tank ID: ❑ In-Tank Gauging Pro e. Model:_ ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ` 61 (c S"P 4.r,rr ❑ Annular Space or Vault Sensor. Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci ui ment Me and model in Section E on Pae 2). ❑ Other(s eci ui ment and model in Section E on Pae 2). Tank ID• Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci a ui ment a and model in Section E on Page 2). ❑ Other(s eci ui ment type and model in Section E on Pae 2). Dispenser ID: ( Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). X PC> M ❑ Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dis user 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). ❑ 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). ❑ Dis nser 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 Certification 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 Q1__. Technician Name(print): 1-L Signalw:!: f Certification No.: ) ''" ' License. No.: Page 1 of 3 03/01 Monitoring System Certification