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rS&V 92 <br /> f forba--ig4t <br /> 1 <br /> 7pUAUTY 219 7YNO a'F UNIMAG OUNU 7ilNKS'AY'Al'br)RDABIX-,RATIW' <br /> ,post Qhke,sox 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0x12 <br /> General Information <br /> FacilityName: �. r.� i Y1�,t H eD(^►rlrlr t U°.ti1 t f Bldg.No.•.... <br /> Sitc Address:_37EL S. A Ov s A__12 f j__ City: ��'P,�,,. � Zap' 9Jd�oyc <br /> Facility Contact Person: /o/�7l�4' __ Contact Phone No.:( 113'339? <br /> Mako/Model of Monitoring System: AV ZZL Ir Tate of Testing/S(xvicing• <br /> B. Inventory of Equipment TesteWCertified <br /> cam enc the a e bow=to indicate=c=ig=• 1: <br /> TD: p��5e� Tank IUD: <br /> Cr3'tn-Tai Gauging Probe. Model: t a ❑In-T mk Gauging Probe. model: <br /> E:(Annular Space or Vault Sesssor. Mcxtol: ❑ Annular Spare or Vault Sensor. Model,._. <br /> Q"'Pipinng Sump t Trench Sensor(s). Model: /C S— 3 O Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump 5ensor(s), M(N.lel: <br /> O Mechanical Line Leak Lktexwr. Model: ❑ Mechanical line Leak.Detector. Model: <br /> ❑fkctronic Line Leak Detector. Model: ❑ Meetronic Une Leak Detector. Model: --- <br /> Tank Overfill/High-Ltvcl Sensor. Madel: O Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(swify EquiLmnt=and model in Section E on t'a be 2). Q Other equipment=aad n,Wei in Section E on Pa•e Z. <br /> Tank IX): Tarok ID: <br /> O in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Madel: 4 Annular Space or Vault Sensor. ModcL <br /> O Piping Sump/Trench Sonsor(s). Model: ❑ Piping Sump/Trench Scnsor(s). Model; _ <br /> O bill Sump Sensor(s). Model: ❑Fill Sump Sensof(s). Model: <br /> ❑ Mechanical lane Leak Detector. Model: ❑ Mechanical line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: O Electronic Lute Leak Detector. Morel: <br /> ❑Tank Overfill/lligh-Level Sens(u. Model: ❑Twik Overfill/High-Level Sensor. Model: <br /> ❑Other(sCgifx equipment type and model in Section E on Pm 2). O Other(s rxa ui mem=and model in Section E an Pa a 2). <br /> Dispenser ID: Dispenser ID: <br /> L1 Dispenser Containment Sensor(s). Model:_... _ ❑I>ispenser Containment Sensor(s). Model: <br /> O Shear Valve(s). ❑Shear Valvc(s). <br /> O Dir ser Containumt Float(s)and G91ain(s). Q Dir ser Containment Flo s)and Chain(s). <br /> Dispenser ID: Dispeumw IID: <br /> 13 Dispenser Containment Sensor(s). mom; ❑ Dispenser CAniftimnent Sensor(s). Model: <br /> ❑ Shear Vaivc(s). O Shear Valve(s)I <br /> ❑ Lhx ser Containment Most(%)and Chain(s). O Dis ser Conrainnaent Fdoat{s and a hain(R). <br /> Dispenser ID: Dispenser W. <br /> ❑Dispenser Containment Sensor(s). Modal: _ O Dispenser Coutniument Senn(r(s). mmiol: <br /> ❑ Shear Valve(s). G Shear Valve(s). <br /> Obis ser Co ntainrmt RaWsj and Chain(s). v Dir ser Containment Float(s)and Chaiu(s). <br /> _j <br /> •if the facility contains more tanks or dispenser;,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I comity that the egUi pmigit identined in this document was inspectediserviced in accordw&Lg with the manmt°.iaWVr,' <br /> Attached to this Cortiflmdon is information(e g. manufacnu+ern' cbwklists) ry to verity that this information is <br /> correct and a Plot Plan showing On kyout or monitoring egWpment. For any(xiuipment capable of generating such report,,I have also <br /> attached a copy of the report;(check all that apply): ®System set-up ❑Alarm histery report <br /> � 0 . <br /> w_ <br /> I ectuliciam Nam <br /> (print): „`✓le, . A�/N9�4►(1 Signatwc: L. _ <br /> Certification No.: Licensee.No.: <br /> Page 1 of 3 03/111 <br /> Monitoring System Certification <br /> !g 'd zi TO-61.L (602) e22 :80 *b0 02 .odd <br />