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�10N-L fc For :grulaority Cited:Chapter 6.7, Health' This form must be used to document testing an, monitoring system control oanel by the teehnich The owner/uperaror must submit a copy of this fo A. General Information Facility Name: }- 1 � � + Site Address: 14 t� Facility Contact Person: Make/Model of Monitoring System: el. RING SYSTEM CERTIFICATION By:9ll Jurisdicrions Within t/te State of California tnd Sa}ery Code; Chapter 16, Division 3, Title 23, California Code of Regulations servicing of monitoring equipment. A Sel2arate certification or re ort must be re azed for each Who performs the work. A copy of this form must be provided to the tank syst n to the local agency regulating UST systems within 30 days of test date. em Owner/operator— B- Inventory gfEcluipment Tested/I ertilfied Chick the appropriate buses to indicate specific eauimrnt iue rc[ed/errt Tank ID: - 0 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Piping Sump /'french Sensor(s). Model: _4 7 —jC�l- -2)0f:� ❑ Fill Sump Sensor(s)• Model: Model: [Mechanical Line Leal: Detector. Model: ❑ Electronic Line Leak Detecror. Model: ❑ Tank Overfill / High -Level Sensor. Other (specify equipment type Model: and model in Section E on Page 2). Bldg. No.: City: C`r,� Zip: Contact Phone No.: ( ) ►Z___ Date of Testing/Servicing: 10 -1-7- Tank ID: (q I ❑ In -Tank Gauging Probe. ,Annular Space or Vault Sensor. Model: '[y Piping Sump / Trench Sensor(s). Niodel: Q— e Model -�� ❑ Fill Sump Serisor(s). -- ,6Ivlechanical Lute Leak Detector. ❑ Model: Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment Model: Tank ID: type and model in Seenon E on Page 2). - ----- Tofapnlk- ------------- RWispcnser ID: [� In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Tank Gauging Probe. Model: ❑ Piping Sump / Trench Sensor(s). Model: nular Space or Vault Sensor. Model: ❑ Fill Sump Sensor(s)• Model: ing Sump / Trench Sensor(,)•Model:❑ Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Model: ❑ Flectronic Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑'rank Overfill !High -Level Senor. Model:❑ Other (specify equipment rope and model in Section E un Pave 2Tank Overfill / High -Level Sensor. Model: ❑Other (specify equipment type and model in Section E on Page2)Dispenser 1D: i --2 Con [air.., Sensor(s). Model:spenser ,,Dii{1D: '�� t� Dispenser Containment Sensor(s). El Shear Valve(s). () ModelC43��,.,�j ❑ Dispenser Containment Floats) and Chain(s). ❑ Shear Valve(s). _ Dispenser Ill: 15 Dispenser Containmenr Flohain(,). — --- El- aL(s) and C_ J.Dispenser Containment Sensor(s). Model; Dispenser ID: --�1`� / Dispenser Containment Sensor(s). ❑ Shear Yah�e(s)' ensor(s) Model:1�� ❑ Dispenser Containment Float(s) and Chain(s). ❑Shear Valves}. ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Q Di,peitser Conutinment Sensor(,). Model: Dispenser 1D: ❑ Shear Vaive(s). ❑ Dispenser Containment Sensor(,). Model: ❑ Dispenser Containment Floar(s) and Chain(s). Shear Valve(s). '!t'[he facility contains more tanks or dispensers, copy this form. Includein matpen for Containment Fandt(s) and ser at (s). facility. ank C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordant tt) guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify thatthis information correct and a Plot Plan showing the layout of monitoring equipment. Foran a with the manufacturers' attached a copy of the report; (check all that apply): y eq ment capable of enerat, oration is PPl')r System set-upg such r Torts, I haye also Technician Name (print): Ton Fontana Alarm histor port �� Certification No.: V.R.A23686 I.C.C. 5289227-U.T. Signature. Testing Company Name:U.S.T. Com liance Testing Inc.License. No,: "A" Gen.En . 846288 Testing Company Address: P.O. Box 580 Ceres, CA 95307 Phone No.: (209) 595-4489 Page 7 of 3 Date of Testing/Servicing: Rev (2/08)