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MONITORINGSYSTEM C"!ER171' CATION For Use By AD Jurisdictions Within the State of California Authoriry 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 tea&g and services of monitc1bg equipment. Asenarate ceMfleation or report must be trtana-1 for each monitoring system conte l oanet by the technician who performs the work. A copy of this form most be provided to the tank systwu owueriopwum. The uwtiodoperawt trwst aubuiit a LVPY of uun tatm to circ iacai agency regulaung UST systems within 30 days of test data 471 \IYYY�{Y iRYVI �aN�YV1/ Facility N== L rllc^ Bldg. No.: LA JLt icy.I rAt C54 Lip: Facility Contact Person: � Contact Phone No.: (AS 11) )Erb- rnU6v Make/Model of Monitoring System 3 i Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Lean no 81=rUle Do=e a7 Wa= -0• Tank M. Tara aur. O In -Tank Gauging Probe. Madel. O In-Tmk Gauging Probe. Model: _ Aane* Spam or Vsalt Sensor. Madel: J alar Spada or Vanit Sensor. Model: ping Sump / Trench Seasor(s). Model: 43*4ping Sump / Trench SensoKsy Model: ' O Fiii Sump Senwa s). Model 0 Fill Sump Senxr(s). Madel: Latta Leak MUctor. Model F 'al Lane Leak Detector. _ Mom: r- E P PZK adrenic Line Leak Detester. Model: O Electronic Lane Le9Jt Detector. Model• Fechanical nk Overfill ( Wiigh-Level Sensor. Model: O Tame Omfill / tGgit_LeveJ Sensor. Model: tt= tri t and model in Section B an 2 LlOther tritrent and model in Section E on Px 2). ID: Tank il)- O Annular Space or Vault Seasar. Model: O Annular Space or Vault Scusor. Model: O Piping Sump / Trench Sensor(s). Model: CJ Piping Sump i Torch Senor($). Model: O Fill Sump Scasor% Model: O Fill Sump Scnsor(s). Model: 13 Mechanical Line Leah Detector. Model: -- O Metdianical Line Leak Detector. Model: U Elecxroatc Line Leak Detector_ Madel: U hiectrumc line Leak Detactor. Model: O Tank OvctS11 / High-Uvcl Sens. Model: O Tank Overfill / high -Levet Sensor. Model: ❑ Other ui matt qw and MOW in Section 8 on P 21` O Other ui treat rVX and model in i;c an E on Pao 2). Dispenser Coat:tinatcnt SetTsot(s) Made%L`>� Containment Sensor($). Model: o Shear Valvc(s)_ o Shear Valve(55. 0 DimEME Coamatrnatt Bloats and Chain(s), I © 2ilka= Containment Float(s) and Chains . ,iLDUpenser Containment Scnaor(s). Modc1"i ,l,oOLMpenser Containment Sr mor(s). Model? 'ki' Y2�i ❑ Shear Valve(s). 0 Shea Valve(s). O D' Containment FhxKs and Chains . D neer Containment flo!g5j and Chain s). Dispenser 11D: Dkvcnser M. O DispenserContainment Scn3ur(s). Mode: L7 Dispenser Containment Senmot(s� Model: ❑ shear Valve(s). O sheat Valve($). Obis user Containment Float(s) mid Cbain(s). O Dispenser Containment Float(q and Chain(a). nr utc facility cunu= more tanks or dispensers, copy this fom lnctndi information for every tank and dispenser at the facWty. C. Certifltdon -i cer" that the equipment mmmw in"] ] oatment was bgwcted/s"Y1cxd to a000tda= with the M*onfocttlre& guiddine- wttaded to fffi C i irlm (a g., naafi' cheddtm) aeetx wl to rerW coat " Wormatkm !s correct and a Plot Plan showing the tayout of monhto equlpa- mt. For tiny eq meat capable of gemradngmw reports, I have also attached a copy of the report; (cheeW apFly): giyl em set-up ig Willy Nes Technician Name (print—�[St�t. I Sigiratnae: - Cettification No.. CXYc, -CM-1 l41 'taellse. No.. Testing Company 1+1t1me T.rllt°_ . Phone No.: (_2Qf3_ Site Addresspa : 11 t "Gmy 4l Dau of'l'sstinglSzty cut / �• Monitoring System Certification Si8'd 557589b:01 96ZT-T2S-602 9NI1S31'dwoo'1Sn:woaA L2:8T S002-8T--inr