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MGNITO�UNG SYSTEM CERTIFICATION D E C dor Use By All Jurisdictions Within the State of !'rrl fprnta RI Aathnrlty C;r¢d- Chaprer 6 ' "ecilth 'd Safely C:•ode, Chapter 16, Division 3, 2VC 23, Califf This form must be used to document testing and s:cing of monitoring equipment. 41�. -A senarate r . nr m E gay¢Or�e6ub A copy of tris form must be provided to the taa)Cco 01 cl by the U4miaian w1 regulating UST systmns within 30 days of test datd�BYgtGm owncrfoporator. The owner/operator must Submit a copy of this for r A. GeneralInfolrMtfon' Facility Name: _ �—`�'� Site Address: W" Facility Facility Contact Person: L� Makernodel of Mouitwins Systc= $. invebtory of Rquipment Tested/Ccrafted rank ID: - - ❑,/itt-Tank t¢attgipg Prone. Modal: (d� . rmul4t SD= nr Viouft fpr. Model: ��yJ[ Fi'� S=p I Trench Seasor(s). ModcL• Q Fill Sump somorw, Model: if"W tanitsl Lino Leak l]tOEctor. Model; Paetroaic Linc Leak Detw or. Model: ❑ Teak Overall I Wgh-L4vel Sensor. Mndcl; E7 Mer (Specify og*M= type and madol in Section and on Pogo Z). Tank ED: 0 In-Tm ra=nging ptobe. [� Annular Space or Vauk Sensor. Mpdol: a Piping'SUMP / Tranob 3tasar(s), Model: t�rodtl: ❑ Fill Sturxp S,*C4 . U M-hmical Line Model Leak Aetector. Qcctronic Linc T �a1c T�ctscrtor. Medal: tank Overfill / iiigh_L4Vef•Sedsar. i� Other (sPcclpyaquMnIal type and Mow;[] Model: Ikt,4 Mr. El Tank ovcrSij / F1i8h-Lovcl Sansor. model in baa Bon 1' Diepuuser b'speaw w�a)m,nmcnt Seacse<Ys). V odel r - Mow ti Dispctadtt ContaintncatPloat(s).And C.hAin(s). bispen�er ID: Im Dispenser t�outalamtrlt 8)' Mme: j SheAr Valyr(s,. -- Dispea� � I'loar(y) aua t hnic(s}. X}ispegaer xD: ❑ Dispenser Coptaiument Scnso s . C Sri.ir vaEro(s) �) Model: [� 1]isptmger containmmat Fladf(s) sad C 'If the facility Contains arro„e(s). 712013 NM F,-NNAL Pcdonas the work to the Iocal ligancy g r-,inid of TuafinwServiong: Tank m: _ III Tapir G-Wr-g Pmbc. M„RICJ_ Annular Sparc or Vault Seasor. Model: piping Suatp /'much SearBor{s). Modal: —� �y Fiu sump S—wo)• Mechanical Model ecu Line Leak D11 otoctar. Strnmi¢ Line Model Leak Detector, Task Overall I High -Level Sensor. Model: Odler (4wify equipmeat type Modal:El and model in Ste); Tank to: ❑ In -Tattle fi t'rone. I --I 0 Annular S'pAce or Vault Serio, Modek. _ ........ Model: Cl Piping 3n[np / Trcn(h Sensor(s). Model ❑ F u sump SwSaKs), "� •= 0 Mcchanical Line Leak LW. ❑ E100onic Lino teak Model: �_--;- Modal: Ikt,4 Mr. El Tank ovcrSij / F1i8h-Lovcl Sansor. Maki: McdcL• — ❑, 0d cr (aptcity cgwpm=t"—`T h'Pe and atodei in Samson E o. o0 D&Pemer ID: Ll s� CO "nmetu Scnwr(s). MOM_ ❑ Dispense C08) nWntpeat Floe;(s) and ChaipU)_ ��D11lIlapenser ID: - D4pc= Containment S=or(s). LJ shm VmVn(a), 0 D ogift PloaffS) At Model: chwa(s), DiBpeaaer iD: Dispenser comaitTraent M sensc>;(s) adai• Sheer Yalvc(s). - d Dispeacer nmant lei C -Py thTS form. Incl wu(s) and chain(4)• C. Certweatiol� - I cert; l'd° �>�tion for every tank and Ideon fy that the equipment identified in thh d ser at the facility. > esi Attached to thio Certification6cMO3,"t was,UPeet.&SerViCed in accordance with the p correct and a Sites o information iter (o.g, rnanufacturpra' eh also attached a co � leu ahowiag rite layout of manitorlirg ;aipm�ent. For � 1 eti"hniaiau Natae PY of the report; (check rril taw,• �,p$): f System setup, is �, t "`p� ° vuer ilr sto verity ftt u�41 ( - Toh Fontana Elam CeT-t�i"1 a 'a rt ~ -N V.R. A23888 ICC 5289227 UT Tcstirtg C ordp NaleC: y RW U.S.T. C Licen--. Se?Vo.: q- Testing com nCe Tq lnc. 8 Y Address: P.O. Box 580 Ceres Phone No.: CA 85307 208 6938 Date of TT;"A 39H-� G00J SV9 31 -ICI 9�� 9LE:EED, G 6b:bT 2), tiaa is I have I