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MONF -)RING SYSTEM CERTIFT kTION For Use By alll fur:'sdictions Within, the State of California Authority Cited: Chapter 6.7, Healnh a.7d Sa: r Code: Chapter 16, Division, 3, Title 23, California Code afRaffulatiuns This form must be used to document testing and servicing of monitoring equipment A separate rtification or report must be .re aced for each monitoring systelrt caatjg anel by the technician who performs the �t.ork. A copy of this fort.: must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: j iv Teed (�) 4X .437¢ Bldg. iva-: Site Address: M58 Tat w ily t'A A_WLwAX City . S Zip: 521 Facility Contact Person: -W C-AvE Contact Phone No.: ( } Nlake/Mode1 of Mortitoring System: _VERDE EL 1roe r Tt.S - 3 O Date of Testing/Servicing: %1/ tat06 B. Inventory of Equipment Test ediC ertified Check the appropriate boxes to indicate specific equipment inspectedl5erviced. q Tank ID: - t1f11 AQW7 Tank ID: Dt6sr-t_ j 0 In -Wank Gauging Probe. Model: W730- /dg i In -Tank Gauging Probe. Model: __k4739d -Z4?? �9 4nnutar Space or Vault Sensor. Model: ��/'3�?- 30/ M Annular Space or Vault Sensor. _ Model: 7145 1-" 30/ Piping Sump 1 Trench Sensor(s). Model: $) Piping Sump ! Trench Sensor(s). Model: q�j 10 Fill Sump Sensor(s). Model: 7997i# • .2-00 1P Fill Sump Sensor(s). Model: 11OE' I 1 Mechanical Line Leak Detector. Model: �Tg_ snX oil-,btil Mechanical Line Leak Detector. � Model: _*V-jm b ,I ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: � Tank Overfill/ High -Level Sensor. Model: _ 117510 -10 9 51 Tanis Overfill / High -Level Sensor_ kiodel: T'`!?_"V-W9 Other (s ecifv equipment type and model ir. Section E on Pake 2). 5D Other (s eciN e uipmert type and mode! in Section. E on Page 2). Tank ID: PWAd IUM Z In -Tank Gauging Probe. Model: AW7 3'40~ 141 ❑ In -Ta z Probe. Model: -- - �rtn dar Space or Vault Sensor. Model: Za�3Ba -301 ❑ Annular Space or gersor. M ei: Piping Sump / Trench Sensor(s). Model 7e4Y3R7 [D ❑Piping Sump !Trench $ensu el- - Fifl Sump Sensor(s). Model: ?9Ar3LW _."W ❑ FilI Sump Sensor(s). l: 10 Mechanical Line Leak Detector. Model: # f VTRA srP• mus ❑ Mechanical Line Leak Detector. Modei: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Modei: A Tank Overfill / High -Level Sensor. Model: f'ty3`'i o -eof ❑ Tank Overfill! High -Level Sensor. Model: Y1 Other (s ecifv equipment t e and model in Section E on lea e 2). ❑ Other (speciEX equipment t e and model in Section E on PaSe 2). Dispenser TD: t`;, Dispenser ID: 7-ff 109 Dispenser Containment Sensor(s). Model: 7tYJbV -mar 'W Dispenser Containment Sensor(s). Model: 7fg3t"k:)-.70t T Shear Vaive(s). It 5hear Valve(s). Di(Dispenser Containment rtoai(s) and Chain(s). O Dispenser Containment Fitiat(sl and Chain(s). ®� Dispenser ID: s-jDisperser IB: 1-10 j Dispenser Containment Sensor(s). Model: 71r/30 Wit V Dispenser Containment Sensor(s). Model: Www- IwQk Shear Valve(s). a Shear Vaive(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: C- t0 Dispenser ID: 11-42" Dispenser Containment Senser(s). Model: 711f ? 2 M Dispenser Containment Sensor(s). Model: Sit Shear Valve(S). M Shear Valve(s). '❑Dis enser Containment Fltiat(s) and Chain(s). h C Dis enser Containment Float(S) and Chain(s). =tf the racillty contains more tanks or dispensers, copy flus form. Include information for every tank and dispenser at the facility. C. Certification - 1 certify that the equipment identified in this document was inspectediserviced 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 equipmetirpeble of generating such reports, I have also attached a copy or the rekRort; (check all that applv): W, Systern set-up ❑ teff/01 Technician game (print): ffM1ttjP SKi'r14 Signature: Certification No.: 263352 - UT License. No.. 70399 Testing Company Name: R M C C...•rgs2 ve;--rto e1 Phone No.: ( 9 51 ; 245 - 5-3 Z3 Site .address: ljoaS8 Tnt+ge ry Ply S roe-w-ro j. C--,&.4 5219 Date of Testing/Servicing. ft /10 jpL UN -436 - 114 Page 1 o17 Rev, 06,0-;; OI ww,unidocs.org