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K9 0 f AMA � . r t 'QUALITY TESTING OF UNDERGROUND TANKSATAFFORDABLERATES' 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 • i ' General Information Facility Name: c sWlale,771, Lq Bldg.No.: Site Address: `41 OW do Of 0 > ® City: �t, Zip: Facility Contact Person: Contact Phone No.: -, `/ j Make/Model of Monitoring System: "` 75 ZOP I Date of Testing/Servicing: / / B. Inventory of Equipment Tested/Certified Check the a2progirinte boxes to indicate mecific equipment Inspected/serviced: Tanis im Tank ID: ❑ In-T• k Gauging Probe. Model: �� ❑ In-Tank Gauging Probe. Model: _ UCn�ular Space or Vault Sensor. Mo Cd Annular Space or Vault Sensor. Model:_ S W-fi-ping Sump/Trench Sensor(s). Model: 1`� tt, / ping Sump/Trench Sensor(s). Model: r:<',(!2 ❑ 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(specify ui Ment Me and model in Section E on Pae 2). ❑ Other( ' e ui Ment a and model in Section E on Pae 2). Tank ID: Tank 11): ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gouging Probe, Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Seasor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fm11 Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spSEffj EquipMent a and model in Section E on P e 2). (3 Other( eci !i Ment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: j ❑ Dispenser Containment Sensor(s). Model: 42 14 '4 : ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Di nser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ensor(s). Model: P-C 2 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)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). ❑ Dispenser 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 wasinspected/serviced in accordance with the manufacturers' guidelines. Attached to this'pertification is information (e g, manufacturers° checklists) necessary to verify that this information is -correct and a Plot Plan showing the HayouE of inanitoring equipment: For any•equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System setup ❑Alam history report Technician Name(print): LI Signature: Certification No.: Oa ` 0 3(0 License.No.: ®-iTi_ L13 I CC 52-LA9 t5 Of