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Afforba-AT 't 9 ?004 'QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDA$Mv' rW1RONMEN7 N C%N7- Post Office Box 36 Thornton, Car. 95686 (209) 794-0102 FA General Informatio Facility Name: D vc�r Bldg.No.: Site Address: "� t•v �L Zip: �/410 Facility Contact Person: )6%-m Contact Phone No.: ( ) 3 —zoa3 " Make/Model of Monitoring System: __1,r 1 r\j Date of Testing/Servicing: Z2-_/e7/ / O-1 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecific equipment inspected/serviced: Tank ID: Tank ID: Crin-Tank Gauging Probe. Model: UTn-Tank Gauging Probe. Model: C31anular Space or Vault Sensor. Model: 7_511a7 El j pular Space or Vault Sensor. Model: LY ping Sump/Trench Sensor(s). Model:?S� Gf w G� [a piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U-1Clechanical Line Leak Detector. Model:SJP�{'h��_ Q-��anical Line Leak Detector. Model: fir` <af7 7P� ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). r13 nk ID: Tank ID: . / In-Tank Gauging Probe. Model: O?=Tank Gauging Probe. Model: �.T� AD Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: C�iping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: 3-Rechanical Line Leak Detector. Model: ::`<'�W 1 i .4�7 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). 0 Other(snecia equipment=e and model in Section E on Page 2). Dispenser ID: ! ., +, Dispenser ID: -::z A --2,• ❑ Dispenser Containment Sensor(s). Model: 1- 6 t-1 4- ❑ Dispenser Containment Sensor(s). Model:7775 P L4 't- 0 Shear Valve(s). ❑ Shear Valve(s). ' ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: f + Dispenser ID: " � U__ ❑ Dispenser Containment Sensor(s). Model: 7` O Dispenser Containment Sensor(s). Model: 7`1S "' A-- Ll Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). 0 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 was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm histcry report Technician Name(print): y�� t�/ 1 1.-1,.L k R Sgnattn Certification No.: License. No.: Monitoring System Certification