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I ¢' 3W- 5 ia@ G9 -17 y 'QUALITY TESTING OF UNDF_PGRO UND TAMUAT AFFORDABLE RATES' 416 2nd Street Galt, CA 95632 (209) 744-0112 ` ` General Information ' wA �[�' 1 / Facility Name: W iFsT t� .N F_ T— l ka" \(Al� Bldg.No.:�_ Site Address: 3 J 0 0 WEST �tvE. City: ��"T"p nJ Zip: Facility Contact Person: DAA Contact Phone No.: - 1 �p8 Z Make/Model of Monitoring System: FDF ®"(" _7L-S. 3A-p Date of Testing/Servicing: / - / B. Inventory of Equipment Tested/Certified Check the appropriate boxes to.indicate ecifec equip ment ins eeted/serviced: VTa : C>G'-T' T ID:nk Gauging Probe. Model: !�G! -Tank Gauging Probe. Model:ar Space or Vault Sensor. Model: 2G7 ❑ nular Space or Vault Sensor. Model:g Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model:—_ —- ❑ 51 Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:Z/w 6000 .grMechauical Line Leak Detector. Model: FE P T2d 13 Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Other(s eci ui ment a and model in Section E on Pae 2). El other(s equipment a and model in Section E on Pae 2). Tank ID• Tank ID: ❑ In-Tank Gauging Probe. Model:_ _ ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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(s equipment a.and model in Section E on Pae 2). 1-1 Other(s eci ui rnent a and model in MIP,,ge . Dispenser ID: ' 4 2-- Dispenser ID: ❑ spenser Containment Sensor(s). Model: ❑ Shear spenser Containment Sensor(s). Model: s). Shear Valve(s). Dispenser er C Containment Float(s)and Chain(s). Xj Dis enser Containment Float(s)and Chain(s). Dispenser ID: 'i'" Dispenser ID: � e�.- � ❑ ispenser Containment Sensor(s). Model: r-Aisgenser 'spenser Containment Sensor(s). Model: Shear Valve(s). hear Valve(s). Dis nser Containment Floats)and Chain(s). Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). I ❑ Dis nser 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 was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this certification is information (e.g. manufacturers' checlttists) necessary to verify that this information is correct and a Plot Plan showing the layout of tnonitorin q ' ent: For any a ui nt capable of generating such reports,I have also attached a copy of the report;(check all that apply): ystem set-up Alarm history report Technician Name(print):_L, 4A/f �1 i i a�20 Signature Certification No.: /� License.No.:_ (T # ,�j"Z j� E9 uT OWL ate- t� l� Monitoring System Certification