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MON)i rORING SYSTEM CERTI*ATION For IIse By Ali Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health mud Safety Code; Chapter 16, Division 3, Dtle 13, California Code of Regulations This form must be used to document testing and servicing of monitoring equipmeaL A se r@t�certeFication or rcoort must be pt-Onatcd for each monitoring g m control panel by the technician who performs the work. A cop}of this form must be provided to the tank s}stem owner/operator. The ovim/operator must submit a cop} of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: T/L A" foArrA U ,/NC , Bldg. No.: Site Address: 3th!e W,_/NAe RMe'rgw . City: Tf2A" ieA' Zip: q S37G Facility Contact Person:_ /CHAA M Contact Phone No.: Zo 7 g3�f- Zoo Make/Model of Monitoring System: ,3�SO Date of Testing/Servicing: _L1/ B. Inventory of Equipment Tested/Certified LLeb tae roue base,to Mdleate gna ZM=impected/servit"; Tank 2D ! /2/Cao it ins lr 9( Tank ID: -ZOr 60 o tet+V 8 ■ ht-Tank Gauging Probe. Model tYZ14o /09 ■ In=fink Ganging probe. Mode}: �y79'90-1 d 9 6 Annular Space;x Vault Sensor. Model: 741 yr,Q-3o? ■ Anm la Space or Vault Sensor_ Model: -Tk2 _g-3oZ- •Piping Sump/Trench Sensor(s), Model: Oj�l y IIA-0 oD i Piping Sump/Trench Sensor(s). Model: 07f y&PC nra p * Fill Sump Sensmis). Model: Q Fill Sump Semor(s). Model: * Mechanical Line Irak Defector. Model: /'►r G n A Mechanical Lice Leak Detector. Model: ViF t 4) Zoon ❑ Electronic Line Leak Detector. Model: Ll Electronic Lice Leak Deledor. Model: • Tank Overfdl/High-f.evel Sensor. Model: &4L L .F2eyn-r-- X Tank(Teri-ill/Fligh-Level Sensor. Model: wkr- ❑ (khnr (v ui th and model.in.Section E on Page 2). U (seer( ifvequipment h and model in Section E on P 2). Tank ID: - 000 tAe J bhoTEL Timis ID: 6 In-Tank Gauging Probe. Model: O73 IRO -/V 9 0 In-Tank Gauging Probe. Model: IN Annular Space or Vault Sensor. Model: 74 ci JAn- 36 7- 0 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 07$4V3L0 -2.n P ❑ Piping Sump/Trench Sensor(s). Model: O Fill Sump SensWs). Model: O Fill Sump Sensor(s). Model: • Mechanical Lime Leak Detector. Model: t/I r!^ 4)Zcw, _ O Mechanical Line Leak Detector. Model: ❑ Electnmic Line Leak Detector: Model: U Electronic Line Leak Detector. Model: ■ Tank Overfill/High-Level Sensor. Model: t4 LwkT ❑ Tank Overfill l lligli.Level Senor. Model: ❑ ()thcr iii=pmmt on nook)in Section E P e 2). O Otho i-- tri t h and model in Section E on P 2). Dispenser ID: 2 Dispenser ID: Or L - i Dispenser Containment Sensor(s). Model: 071y5 eI r * Dispenser Containment Scruto(s). Model: 079 Y310-loo ■ Shear Valve(s). * Shear Valve(s). Ll Dispenser Containment Floats and Chain(s). ❑ Di su Containment Fiera s and Dispenser M-. OF 3A C sO. r ni ispe`aerConWmaentSensl (s) Model: O7943ft -2441 Dispenser CootammntSeisor(s). Mad :f SheaValve(s)- ■ Shear Valves). 79Y 390 26�� LU Dispenser Containment F12a s and Chaim(s). ❑ Dispenser Containment Ff s and Chain(s. LLU33r�E D: Dispenser ID: r Containment Sern r(s). Model: E3 Dispenser Contaitment Senwu(s). Model: lve(s). t7 Shear Valve(s). Containment Floats and Chain (s). ❑ Di. Comtainmeat Fl s atM C s. *If the facilit) contains more tanks or oiisperuers,col» this form, Include information to every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was luspccted/servicrd in accordance with the manufacturers' guidelines. Attached to this Certification is information(cg, manufacturers' checklists)necessary to verify that this Information is correct and a Piot Plan showing the layout or manitoring equipwmn For any equipment capable of generating such reports,I have also attacheij a copy of tllerrepart; (clterk all iker apply): em sof +/ )atm histUty tYpoti Technician Name(prial); &1E C% �'(4trL7"/4+re1/ Signature: Certification No.: m - tT l' --OL 9 3 Unease.No.: D3 /L YO — Testing Company Name: Dialysis North Phone No.: ( 330 ) 219-1906 Site Address:TRACY Ek 7Xe Ne, 31/a ,d /t1ACA4rcr~rr Tkg", eA Date of Texting/Servicing: �__ ' +f Par t ofs niPor Monitoring System Certification