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i; <br /> ffarbraA-W Tie f <br /> QUALITY TESTING OF UNDERGROUMD 7AAfJUATAFF0RDA <br /> Post Oce Box 36 Thornton, Ca. 9568 M 112 ... <br /> aNOV 2 ENVIRONMENT HEALIH <br /> ' UeneralI o ation IT/SEW'GES <br /> Facility Name: 100 1 ,- -HEALTH Bldg.No.: <br /> Site Address -7 15— 13 z - Zip: <br /> �' <br /> Facility Contact Person: Contact Phone No.: (P 0 j') <br /> Make/Model of Monitoring System: L , Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea roria boxes to indicate ec�ment ins ected/serviced: <br /> Tank ID: V/ '.,- Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: lq4 ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: S- a ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model:_ S - ElPiping 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 /> ❑ Other(sEecifl S2ui2=nt!jpe and model in Section E on Page 2). ❑ Other(s eci ni ment LYEE and model in Section E on PaLe 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: 13 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 /> ❑ Other(s ui ment a.and model in Section E on Pae 2). ❑ Other(s ui rent and model in Section E on Pae 2). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenses Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dis enser Containment Float(s)and Chain(s). Q.DisLnenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ 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 of -monitoring 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 /> h <br /> Technician Name(print): ' , p Signature: _ <br /> Certification No.: ®� f � License.No.: <br /> !CC 5249 k5 - LX" <br /> Monitoring System Certification <br />