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iTR -e% 94 y QUALITY TESTING OF UNDERGROUND 7ANJUA TAFFORDABLE RATES' Post Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794-0112 s General Information Facility Name: as �T Bldg.No.: Site Address: < ��® � ��. City: ' "� Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System:_ ,� 5 ` Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate 2ecific equipment inspected/serviced: Tank ID: / / C-�, (n�-—c s-I -oM2). ank ID: 2)t) �c Go 6 ❑ In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model::22L67Annular Space or Vault Sensor. Model: ��2' ❑ Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: ❑ Sump Sensor(s). Model: Fi mp Sensor(s). Model: RO'Mechanical Line Leak Detector. Model: echanical 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 eci a ui ment a and model in Section E P!LeOther(specify ui ment type and model in Section E on Page 2). Tank ID: Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model:_C. f R` gar a ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 2-: ❑ Piping Sump/Trench Sensor(s). Model: ❑ WSurrip 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: [Dispenser Other(s eci u ment and model in Section E on Page 2). ❑ Other(s eci equipment a and model in Section E on Page 2). enser ID: ' rP Dispenser ID: ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). enser ID: Dispenser ID: ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). 11 Shear Valve(s). is enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ID: Dispenser ID: ispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). s enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this fomi. 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 histery report Technician Name(print):_ Signafut % ,f.. 171 Certification No.: 49 License No.: Monitoring System Certification