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V MiZ. IV <br /> f farba-, T <br /> QUALITY TESTING OF UNDERGROUND 7ANKSATAFFORDABLERATES' <br /> r Post Office Box 36 Thornton, Car: 95686 (209) 794-0102 FAX 794-0112 <br /> General Information <br /> Facility Name: Lv f v r l®C� Food /-- L- <br /> Bldg.No.: <br /> Site Address: `� I,t9Ck r(t9d City: ��,` /7 ' Zi 9 6—d-0.65_P <br /> Facility Contact Person: ie(k W Contact Phone No.: <br /> Make/Model of Monitoring System:_Th T S !4>D1 Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicatespecific a ui Ment ins ected/serviced: <br /> Tank ID: is V d_ Tank ID: u {J <br /> irrn-Tank Gauging Probe. Model: �?'!Ut�_ [P-hr-Tank Gauging Probe. Model: <br /> ular Space or Vault Sensor. Model:_ ' SE pular Space or Vault Sensor. Model: <br /> tpmg Sump/Trench Sensor(s). Modelf'tping Sump/Trench Sensor(s). Model: r%PI%!I14 <br /> ❑ FWump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> QlAechanicai Line Leak Detector. Model: ( rJ Weehanical Line Leak Detector. Model:7W tT C? <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(specify equipment t e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). <br /> Tank Rk Tank ID: )D i Yra <br /> ❑ In-Tank Gauging Probe. Model: Tank Gauging Probe. Model: A41 Z*sir <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: �' e <br /> ❑ Piping Sump/Trench Sensor(s). Model: G11 p'g Sump/Trench Sensor(s). Model: `'�,«�&­1 <br /> ❑ Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: B'ge-clianical 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 /> [Dispenser <br /> Other(s eci a ui ment a and model in Section E on Page 2). ❑ Other(s eci equipment a and model in Section E on Page 2). <br /> spenser ID: */ $_.Z,,, <br /> Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: tr f� A- ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ❑ Shear Valve(s). <br /> Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> spenser ID: Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: H A-$ ❑ Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). D Shear Valve(s). <br /> Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> ID: fo Dispenser ID: <br /> Dispenser Containment Sensor(s). Model: rwf daL5 ❑ Dispenser Containment Sensor(s). Model:Shear Valve(s). ❑ Shear Valve(s). <br /> is 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 ofmonitoring 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 /> Technician Name(print):. i 4e J7 tj 1 WL ✓k Sgnatuic: <br /> Certification No.:� License. No.: <br /> Monitoring System Certification <br />