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For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring, system control panel by the technician who performs the work. A copy of this form 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 I)formation Facility Name: ! a tok "" AA n .� WAS Bldg. No.: Site Address: /-S-z4 YI-65 o 4vcr '--- City: 57Dc -TvA) zip: ?3,_Z04 Facility Contact Person: A) Contact Phone No.: (2402 133 - /�71/ Make/Model of Monitoring System: G It -d F/tdo ( JL4C Date of Testing/Servicing: / 7 / 02 B. Inventory of Equipment Tested/Certified C16-1, tho annrnnrinte hnrec to indirnte mecific enninment insnerted/serviced: Tank ID: ' ZU,y0D 6AU-.ow) '016T6-- Tank ID: ® In -Tank Gauging Prob . Model: 4740 2,&6 6U20_ ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: PAD X51) 1 04a d0 ❑ Annular Space or Vault Sensor. Model: 9 Piping Sump / Trench Sensor(s). Model: PAD ZSgZ0000/d ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: es` ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: rn ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- tT'' ■ Tank Overfill / High -Level Sensor. Model: D& P T ge FLAI?pgrt ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify a ui ment ty2e and model in Section E on Page 2). ❑ Other (s eci equipment a and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: NO ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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 eci equipment to e and model in Section E on Pa e 2). ❑ Other (s eci � equipment e and model in Section E on Pae 2). Dispenser, ED: I SAT- Dispenser ID: C Ili _ _ ■ Dispenser Containment Sensor(s). Model:-390_"SCIC61 J 1/ N Dispenser Containment Sensor(s). Model: PAO S9.SOu00tl ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ DispenserContainment Float(s) and Chain(s). ❑ Disj2enser Containment Float(s) and Chains . Dispenser ID: T Dispenser ID: s'AT ■ Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: ?AOSVT0ZT 1 / ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Di enser 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). ❑ Dis enser Containment Floats and Chain(s). irfthP faritity rnntnins mere tanks or disnensers. coov 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 rep�otj ; (check all thatt� 1Y): ■ System set-up K AI m history re ort Technician Name (print): KU S S�ZG KU6EYLS Signature: �( i Certification No.: =-13 — Z6SL License. No.: 7 7 — 1,19Z Testing Company Name:/ li/S/S /LTf f Phone No j S30 ) 279-- G G 6-7 Site Address:�aoo %i ALO.U:;2w- t ��a 57704 'TIWJ OA. Date of Testing/Servicing: � ? Oz Pagel of 3 03/01 Monitoring Svstem Certification