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12114,12015 16:35 2098337676 A ONE GAS PAGE 02/06 MUN WORING SYSTEM CERTIFOA.TION ` For Use By All Jurisdictions Within the State of California Authority Cited--Chapter 6.7, HI alth and Safety Cade; Chapter 16,Division 3, Title 23, California Code of Rogulattons This form insist be used to document testing and servicing of monitoring equipment.-W-wi^r__� ee .r �A separste_SsP 6f"iestr;on or report be prepare for each monitoring syst�ol n by the technician who perforins the work A copy of this form most be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency rcgula6n UST systems within 30 days of test date. . A. General Information OEC 1 4 20% )"acgity Name: j-� 1+�+C� �x S ce4d —1'� @14M NT.H 1 Site Address: Facility Contact Person:_ Contact Phone No.: NlakcModcl of Monitoring System: ( Date of Testizlg/Sarvicing: � 111. Itive>ntory of Equipment Tested/Certified Chick the. ro riaft bores to indicate specific egaipintnt ins ected/scrviced+: Tank 1D• cin Tank ID ❑In-Tank Gehgin Probe. Model: In-Tank Ganging Probe. Model: Annular Space or Vault Sensor, Model: "- tT7 Anntil&r Space or Vnult Sensor. Model: d"1 Piping Sump/Trench Samor(s). Model: 7(` Piping Sump/Trench Sensor(s). Model: �V Fill Sump Sensor{$). Model: Fill Sump Sensor($), Model: J6140auieal Line Leak.Detector. Modcl:y14ILJb21 � Mechanical Linc Leak Detector. Model: %d it 02ft1.Y ❑.0mironic bine Leak Detector. Model: _ _ Q Fiectrrnve Line Leek Detector. Model: _ _ - ❑Tank Overfill I High-Lcvc)Sensor. Model: ❑Tank Overfill/High-Level Sensor, Model: E]Othor(specify etlittllsnent type end model in Section E on Page 2). ❑Other(specify equipment typo and model in Section E on Pago 2), Tank D7: Tank ID: 01n-Tank rsauging Probe, Model: ❑In-Tank Gauging Probe. --- ❑Annular Space or vault Sensor. Model: _ ❑A,wulm Spate or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: _ Q Piping Sump I'rrmoh Sensor(s), Model, , 0 Fill Sump Sensor(s), Model: ❑Fill Sump Scmef s). Model: ❑Mechavical Line Leak Detector. Model: ❑Mechanical Line Leak 1?ctector, Model: ❑Electronic Line Leak i7ctector, Model: ❑F-Imtrvnic Line Leak Detector. Model: ❑Tank Overfili/Kgh-Lcved.Scmor- Model: _ Q Tank Overfill/High-Level Sensor, Model: Otho(specify oquip-onrt)pe and model in Section E on Page 2), ❑.Oihct(specify equipment type and modal in Section E on Page 2). . Dispenser ID: Dispenser ID: 1 n1 Disponsor C.ntairtmcnt Sensor(s). model.:-- 's( __ ❑bis m Dispenser Containment Sensor(s). Model: �+ _ ElShear Valvc(s), ❑Shear Vatve(s). --' CJ Dispenser Containment Float(s)And Chain(s). ❑Dispenser Containment Float(a)and Chain(s). Dispenser ID: ,. Dispenser ID' .79 Dispenser Gvntainment Sencor(s). Model: ±7 ❑Dispenser Containment Scusor(s). Model: �+ ❑'shear vaive(s). El Dispenser Containment Flo s anains [j Shear valve(s).ont �) dCh ()• ©Dispenser CContainment Float(s)and Chaia(s)- Dispeisser ID: Dispenser W: n Dispenser Containment SCasor(a). Model; ❑Dispensw Coominnront Sensor(s). Modes: ❑Shear Valvc(s)- E]Shear Valve(s). ❑Dispanser Containment RgWs)and Cham(s)- ❑Dispenser Containment Float(s)and Chain(s)- *If tbo facility contains marc tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility, C- Certification-I certify that the equipment identified In this document was Inspected/serviced In accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufstctarors' checklists) necessary to verify that this information is correct srnd a Sites of Plan showing the layout of moultoring o�yuipment. For arty eslt�t meat capable of generating such reports,I have also attached a copy of the report,'(check ill that aPP17)t ICJ S�'steurset-up 1Alarm history reporte!: 4\,.1@r+.� Technieim blame(prints Tony Fontana Si cert�atiola�No,. V.R.A23686 ICC 52$8227-UT ' Licelise,No.: A_ =$46288 _ Testing Company Name: U.S.T.C9HW#pnc9 Testing Inc. Qbone Ido.: 209593.4/89 Testing Company Address: P.Q.Box 580 Ceres,CA 96307 Date of Testing/Servicing:, U1V-036—1/6 www,ae;daca ors Rev.01/17/08