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., *: f 1 r UNDERGROUND'QUALITY TESTIMG OF, : '" A , ATESt yENVIRONA0 Post 0jf7ce Box 36 Thornton, Ca. 95686 (2#0�09,"102 FAX 794-0112 OF General Information MAVISTLCAKBldg. '► Facility Name: No.: Site Address: 9E yosF-mi-rc A ve City: Zip: 9i)_336 Facility Contact Person: t,� Contact Phone No.: ( )82-4— 2-- Make/Model of Monitoring System: 6 & L -P Fz:� rry c._ Date of Testing/Servicing: 9 / i /® B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sped Wc aqui Ment inspected/serviced: ank ID: a^7 OC -i Tank ID: In -Tank Gauging Probe. Model: ✓n Z In -Tank Gauging Probe. Model: to A Gr 7._ Annular Space or Vault Sensor. Model: 7 5 � 380- 36-k Annular Space or Vault Sensor. Model: ?9 P3 so ~ ? Piping Sump / Trench Sensor(s). Model: 3 - 2 Piping Sump / Trench Sensor(s). Model: !9 . 5156- Z1C> Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: t -D aooc> Mechanical Line Leak Detector. Model: LD -L ®® Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (seecif2 a ui Ment =e and model in Section E on Pae 2). ❑ Other (s eci a ui ment =e and model in Section E on Page 2). Tank ID: T nk ID: 1 CSE t✓ ❑ - Gauging e. del. In -Tank Gauging Probe. Model: d,'l A ❑ Ann ar Space or an Sensor. del: ❑ Annular Space or Vault Sensor. Model: Pipin Sump / T rich ensor(s). M el: Piping Sump / Trench Sensor(s). Model: 7" `/ 3"�� 2 Fill mp Senso s). el: Fill Sump Sensor(s). Model: Mec ical Lin Leak etector. del: Mechanical Line Leak Detector. Model: t -D Z � Elec nic Lin D tector. odel: ❑ lectronic Line Leak Detector. Model: Tank verfi High- el Se or. del: ❑ Tank Overfill / High -Level Sensor. Model: Other (s eci a ui men and rn ection E o P e 2). ❑ Other (s eci equipment a and model in Section E on Page 2). Dispenser ID: ! �'- Z- Dispenser ID: 5 7 ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: hear Valve(s). timenser Shear Valve(s). Containment Float(s) and Chain(s). is enser Containment Float(s) and Chain(s). D penser ID: 3 `i Dispenser ID: _ "f- Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: hear Valve(s). lig❑ Shear Valve(s). is enser Containment Float(s) and Chain(s). Dispenser 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). ❑Dimenser 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 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): -up Alarm history report Technician Name (print): Certification No.: aM /(,:7, OL ( Monitoring System Certification WOO +, a tiW License. No.: Ilj� ' ( 41 ' 41