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npr 20 04 08: 42a L Facilities Management (2=) 339-7672 p. 4 <br /> Afforba—Z At <br /> LIUAWTFTF..S77N(r OF(INDERGRO(/A(L)7AAfK,'YATA1;X)RDAft1.E1"T 7 <br /> PostL <br /> Office Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 <br /> General Information <br /> FacilityNamc: I Ate-f Wdg,No.: <br /> Site Addrcss: G41:ic: "22 city; /,od, zip: <br /> Facility Contact Person: A& Conmet Phone No.! <br /> M2ka/Modcl of Monitoring Systcm! <br /> B. Inventory of Equipment Tested/Certified <br /> Check tic appropriate boxes to indicate SPocific equipment Inowulediservited. <br /> Tann <br /> D; Tank ID: <br /> I-Tank Gauging Probe. M—Culd; U In-Tjn),,Gauging Probe. Model <br /> � �! k�fj <br /> d'Annular Space of Vault Sensor. 7Model: - C3 Annular Space or Vault Sensor. Model. <br /> 2'Piping sump I TY;nch Sensor(s). Model: A-5— :7 Ll Pilning Sump I Trench Sen%or(s), Model; <br /> U Fill Sump Sensor(N). Modal. Ll Fill Sump Sensor(s). Model: <br /> 0 MoAianical Line Leak Detector, Model: 0 Mechanical Una Leak Detector, Model: <br /> Lj P"mmit;Unc Leak Detector. Modal: 0 Elcctronic:Line Leak Detector, Modal: <br /> 01T,wrik Overfill/High-Level Sensnr. Model'. 0 Tank Ovcrfill I fligb-Laval Sensor. Model: <br /> a Other 6wity a-ui.mint type and model in Section 6 on Paye 2). a Other(specify equipment typeand model in Section E on Page 2), <br /> TAnk.fl): Tank ID: <br /> • in-Tank Gauging Probe. Model: L3 In-Tank Gauging Probe, Model, <br /> • Annular Space or Vault Sensor. Model, Ll Annular Space or Vault Sensor. Modal: <br /> • Piping Sump/Trench Scnsor(s) ModcU 0 Piping Sump/Trench Sensor(,%). Model; <br /> U Fill Sump Scusor(s). Model; L] Fill SUM13 SCASOT(l). Model, <br /> •Mechanical Line Lc*Vetector. Model: 0 Mechanical Line Leak Detector. Modcl: <br /> •Elct:tronic Line Leak Detector. Model: 0 Elcawni`Una Leak Detector. Model: <br /> •Tank Overfill/High-Level Sensor. Model; 0 Tank Overfill/High-Level Sensor. Model: <br /> •Outer(specify cguiEmen(Me and model in Section E on Pae 2). 0 othcr(EecjU cHu! eta type and model in Section C on Page 2), <br /> Ditiltenser M. Dispenser W: <br /> U Dispenser Contaxtunent Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: <br /> C1 Shear Valvc(s). Q Shear Valve(.0, <br /> 0 Drat enser Containment Rom(s)and Cbain(s). ❑-Dispenser Containment Flout(s)and Chain(A <br /> Dispenser W! DINpenur 1W <br /> 0 Disptnricr Containment Sensor(.). Model; 0 DiNpcnsor Containment Scrimor(s). Model: <br /> 0 Shear Valve(.). 9 Shear Vulvc(s). <br /> a DITRwIzontainment RoAt(s)and ChAill(s). D-pis peraser Containment Ploat(,N)and OkAints), <br /> D6penser ID: Dispenser IW <br /> Ddispenser Containment SeA%tir(ii). Model. Dispenser Containment Sensor(s). Modal: <br /> E3 Shear ValveW. 0 Shear vulve(s). <br /> Obis periscr Containment Ronl(s),and ChainW. U Diseenser Containment 1-loat(O and Chain(s). <br /> ,if the facility cootuins more tanks or dispensers,copy this form. Include information for every Lank and dispenser At the(utility. <br /> C- Certificntion-1 certify that the equipment idanfiOud in ails document ww;inspected/serviced in accordanev with the numufstclurers, <br /> guidelines. Attjkd%4!d to this Cerdfication id information(eg.munul'acturen'diecklists) necessary to ver-Iry that this Laurowdon iN <br /> correct and a Plot Plan ohowing the layout of monitoring equipment, For any equipment capable of,.-tucrating-such reports,I have also, <br /> attached i copy of the report;(check all that apply): ClSystem set-up U Alarm histery report <br /> Technician Name(prim): <br /> Certification No.: License. No. <br /> pige I of.I <br /> Monitoring System Cerlireenfirin <br /> eQT :On in n2 jJH <br />