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1 'QUALITY TESTING OF UNDERGROUND 7:4 FA��O, <br /> NKSAT AFFORDABLE RA <br /> r Post <br /> Office Box 36 Thornton, Ca 95686 (209) 794-0102 FAX 794�� y <br /> General Igormatioq <br /> Facility Name: h- WW Bldg.No.: <br /> Site Address:--If toc,> 47�, 1P c� Ci y: 7� C ` <br /> Y� � � -- zip: q5? 1.5 <br /> Facility Contact Person:_ ,t>a n" Contact Phone No.: ( ) <br /> Make/Model of Monitoring System: 1-r Y� <br /> Date of Testing/Servicing: <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate ethic equipment ins ected/serviced: <br /> Tank ID: 1.L ]-- <br /> Tank ID: 17/ <br /> ❑ In-Tank Gauging Probe. Model: 014111 ❑ In-Tank Gauging Probe. Model: -it 4a <br /> ❑ Annular Space or Vault Sensor. Model: </ Q� ❑ Annular Space or Vault Sensor. Model: "9TIOAO, <br /> ❑ Piping Sump!Trench Sensor(s). Model: Oft r� ❑ Piping Sump/Trench Sensor(s). Model:❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical 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 /> ❑ Other(s eci ui ment a and model in Section E on Pa a 2). ❑ Other(s eci ui ment a and model in SectionTank ID: Tank ID: 41 � t_"f❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 1'i''+'❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: C,o/ <br /> ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: a0p,04000 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical 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 /> ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: f?1 /j� ❑ Dispenser Containment Sensor(s). Model: V 'AW®� <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: e2-.Of"17 Q/0 ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). C3 Shear Valve(.-). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(.-). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model:- <br /> 13 Shear Valve(s). ❑ Shear Valve(s). <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(.-). <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;venerating such reports,I have also <br /> attached a copy of the report;(clieck all that apply): ❑System set-up ❑Alarm histcry report <br /> Technician Name(print): !./ T7 1' it9P 11n f ,f <br /> Certification No.: License No.: <br /> Monitoring System Certification <br />