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i QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES` Post Office Box 36 Thornton, ea. 95686 (209) 794-0102 FAX 794-0112 r General Information Facility Name: nJ '�y c_ C� t �J� �' Bldg.No.: Site Address: �D O / u 4_1 { 0 City:t-(7Qa i qk Zip; FS Facility Contact Person: O 1123 i/ Contact Phone No.: Make/Model of Monitoring System:-1"_710Sri IL- JZZ--- Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate-boxes to indicate speciric equipment! ected/serviced: VI k ID: � Tank ID: n-Tank Gauging Probe. Model: 13In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: DUAL, �t vim.-� ❑ Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: (AL S ❑ Piping Sump/Trench Sensor(s). Model: ill Sump Sensor(s). Model: U5 El 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(s2ecify a ui ment a and model in Section E on Paize 2). ❑ Other(specify ui ment a and model in Section E on Pa&e 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 ec' ui ment type and model in Section E on Pae 2). ❑ Other(specify ui ment type and model in Section E on Pae 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: E3Dispenser Containment Sensor(s). Model: Shear Valve(s). E3Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)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). ❑ Dis nser ContainmentFloat(s)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 ConWnment 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 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 eq2!pinent capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up Alsrm histo re rt Technician Name(print): A'00-16 kpl Signattu Certification No.: License o.: 76 Page I of 3 03/01 Monitoring System Certification