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ime L3, c.atijornia L-ode of Regulations This form must be used to document testing a ' -,!rvicing of monitoring equipment. A separs rtification or r ort must be prepared for each monitoring system control panel by , ,chnician who performs the work. A copy -ais fd m 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 OCT 1 8 2002 Facility Name: EN VI T HEALTH Site Address: 3 6 { ��} s� c Ci ERM SE* ty _ S+��t_� ip !S Facility Contact Person: Contact Phone No.: ( Make/Model of Monitoring System: V e eJ-,-= � 4- —7-L_ )p ;as Date of Testing/Servicing: /G B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Inspected/serviced: Tank ID: '45 p��,� Tank ID:_ S 7 �s ® In-Tank Gauging Probe. Model: 'Tt_,Lt Z-ln-Tank Gauging Probe. Model: C1 Annular Space or Vault Sensor. Model: yLo -Annular Space or Vault Sensor. Model: y ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: W Mechanical Line Leak Detector. Model:_ tl �_ ❑ Mechanical Line Leak Detector. Model:_ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-bevel Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). 1 ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 1 ❑ Annular Space or Vault Sensor. Model: Cl Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑.Piping Sump/,Trench Sensor(s). Model: ❑•Fill Sump Sensor(s). . Model: 13 Fill Sump Scnsor(s). Model: C3 Mechanical Line Leak Detector. Model: ❑.Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E3 Electronic Line Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model: . ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tyDe and model in Section E on Page 2). ❑ Other(specify equiPment tyx and model in Section.E on Page 2). Dispenser ID: �-s 1. �_ g TT T-p�p,r Dispenser ID: IS 4- lam \ ,�S 4- Q �� ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ¢ Shear Valve(s). W Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 1 ❑ Dispenser Containment Floats and Chain (s). Dispenser ID: SLS , 2 d-- Q Dispenser ID: I Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: .Shear Valve(s). ❑ Shear Valve(s). J Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Float(s) and Chain (s). Dispenser ID: Dispenser ID: I Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Cl Shear Valve(s). ]Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Floats and Chain (s). f the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. Certification -I certify that the equipment identified in this document was inspected/serviced In accordance with the manufacturers' guidelines. Attached to this Certlfication 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): M-System set-up �U-A,rm ' #oar report chnician Name(print): l �. 2��l(� Signature: rtification No.: / License.No.: 'sting Company Name: 7: ��G[�L I' •� C t - Phone No.:� �6 l2 7-? — c Q CIO ;c Address: 37`t ;c o o 3 Testing/Servicing: l o/ j/_Q-L_ unitoring System Certification Pagel of 3 u.s 03/01 7. t orft6w cernf�tion mb. L!F0