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P W F" r fl b" k ua.® r'wu a.,a uPV— W VP t 1 yrs `i Jr v 01 'QUALITY TESTING OF UNDERGROUND TANKSAT AFFORDABLE RATES'. Post Office Box 36 .Thornton, Ca. 95686 (2",,,,� 794-0112,�'�� 'i��l F General Information A s' q x Facility Name: MIlk MAOr ldg.No.: Site Address: 33 City: Zip: 967_z®'7 Facility Contact Person: ® Contact Phone No.: (?) 915-1 - 874 Make/Model of Monitoring System: VMUL 1&0-r Date of Testing/Servicing: 3 /z7/ B. Inventory of Equipment Tested/Certified Check the ap2rogriate boxes to indicate gecific a ui ment inspected/serviced: T ID: e-7 dc,"l' Ta ID: IA5M -Tank Gauging Probe. Model: �_ -Tank g be. Madel: Al alar Space or Vault Sensor. Model: 7�� ,anular Space or Vault Sensor. Model: WY' 0L® Piping Sump/Trench Sensor(s). Model: `PC U�' Piping Sump/Trench Sensor(s). Model: , `U ® 2,06 ❑ 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(specify ui Ment ty2e and model in Section E on Pae 2). El Other(s aqui Ment and model in Section E on Pae 2). YTk ID: f ��' Tank E[):ZTank Gauging Probe. Model: 14A 61 / ❑ In-Tank Gauging Probe. Model: 9,Annular Space or Vault Sensor. Model: _ ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7Tq777 2 D 6 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FillSump 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(sp22ft SgaipMent tM and model in Section E on Pae 2). ❑ Other(s eci a ui ment a and model in Section E on Pae 2). Dispenser ID: / Z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 13,Dispenser Containment Sensor(s). Model: 2f Shear Valve(s). ZIA=Valve(s). 0"Dis enser Containment Float(s)and Chain(s). oU Di enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 7 ❑ ispenser Containment Sensor(s). Model: Dispenses Containment Sensor(s). Model: Shear Valve(s). hear Valve(s). EI/Dispenser Containment Float(s)and Chain(s). Lzlf 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). ❑Dis enser 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 ofmonitoring yeppment; For any pment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ystem setup lnrm history report Technician Name(print): Zqn/E A//M'9✓ (G; Signature: Certification No.: i License.No.: A 2,7 LIT 077 L -9 044 L:j 6 Monitoring System Certification