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Champfflun A. Box 13059 <br /> Sacramento, CA 95813-3059 <br /> Precision Tank Testing <br /> License No. 73848 CA 800-660-9443 <br /> NEV 800-949-9443 <br /> •(916) 927-1557 <br /> Fax: (916) 927-7345 <br /> _ <br /> MONITORING SYSTEM EQUIP NT CERTIFICATION <br /> Date of Testing/Servicing: /1 D /Q(,� Facility Name: \-001 S": N%O'R .S, 14.0-j Q1 MvL. <br /> Site Address:CM W41 w N1 D w T /�.Ljt City U Q 1 ZiD:Asp 441D <br /> Facility Contact Person` .-.,.?•.1 Q L Contact Phone No.: ) N 1 <br /> Make/Model of Monitoring Systems �Q1P -1 � Location of Control Panel(s):' <br /> Make/Model of Line Leak Detector(LLD):W /A G t•�p SO^ll Crh t LLD Leak Threshold: g.p.m. <br /> Complete the following checklist: <br /> 19 Yes ❑ No* Monitoring system•is operable per manufacturer's specifications? <br /> `g] Yes ❑ No* Audible alarm is operational? <br /> -0 Yes ❑ No* Visual alarm is operational? <br /> 41 Yes ❑ No* Monitoring system is secured from unauthorized tampering? <br /> ❑ Yes Q No* For pressurized piping systems,do the turbines automatically shut down if the monitoring system detects a leak, <br /> N/A •fails to operate,or is electrically disconnected? If yes,which monitoring devices initiate positive shut-down? <br /> ❑ Yes ❑ No For monitoring systems which serve as tank overfill warning devices,does the overfill warning function operate <br /> N/A properly? If so,at what percent of tank capacity does the alarm trigger? % <br /> * In the comments section below,describe how and when these deficiencies will be corrected. <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> Tank M No.:1 Tank ID No.:. Tank ID No.: Tank ID No.: <br /> Annular pace Sensor 0Annular Space Sensor 0 Annular Space Sensor 13 Annular Space Sensor <br /> +D Piping Sump Sensor O Piping Sump Sensor ❑ Piping Sump Sensor O Piping Sump Sensor <br /> O In-Tank Gauging Probe O In-Tank Gauging Probe ❑ in-Tank Gauging Probe ❑ In-Tank Gauging Probe <br /> ❑ Dispenser Containment Sensor(s) O Disperser Containrre nt Sensor(s) O Dispense Containment Scnsor(s) ❑ Dispenser Contairuncrit Sensors) <br /> O Mechanical Linc Leak Detector O Mechanical Linc Leak Detector O Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector <br /> ❑ Electronic Line Leak Detector ❑ Elcctrtronic Line Leak Detector O Electronic Line Leak Detector O Electronic Line Leak Detector <br /> Comments: 'jTO'Q/1 ac. �;�t i f", Cv !-�s'1�; r4 ka " ! kJE <br /> RWSO_UCT L\ '��•'g ram l�+..1ty„, ��b 1�`tom 1 w Nov r..t•r• <br /> I certify that the equipment identified above was inspected/serviced in accordance with manufacturers' guidelines. Attached <br /> to this Certification is information (e.g. manufacturer's checklists, etc.) necessary to verify that the above information is <br /> correct and to describe any repairs, replacement,or recalibration of equipment. <br /> Name of Qualified Technician(print):W( I I l Q ti % Signature:'W <br /> Testing Company Name:rLS l f oh S2t ol,\ Phone No.: lata <br /> LN-036 Rev.09/17197 <br />