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RECEIVED MONITORING SYSTEM CERTIFICATION JAN 0 2 M5 For Use By All Jurisdictions Within the State of California Authority Cited:- Chapter 6.7, Health and Safety Code; Chapter 16, Dtvision 3, nrle 23, Cal jdrnt".t W,NTAi This form must be used to document testing and servicing of monitoring equipment, -e-i3ert rig -A5' thea ar cote certi>ico ion or ronort-must L"Martcl for each monitoring system control nand by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owncr/operator must submit a copy of this forst to the local agency regulating UST systems within 30 days oftest date.-. i A. General Information Facility Name: A =:& q1""' -- -- -- _ Bldg. No.: Site Address: City: M�)_�_� Facility Contact Person: ein11.V512 -- Contact Phone No.: ( } Makofflodel of Monitoring System: '\(.�y�acl � i— "j '�,�� Date of Testing/servicing; i ! t , t B. Inventory of Equipment Teated/Certified Ch#� lr the jihnrnnrlate hnies to indicate anecific toulantent inspectedIxervicedl; Tank ID: Tank ID: ❑ In -Tank Gauging Probc, Model: ❑ In -Tank Gauging Probe. Mudel: Annular Space or Vault Sensor, Model: —' 1 Annular Space or Vault Sensor, Model; 40 Piping Sump /Trench Seegor(s), Model: — .e it" _ _ - _ Piping Sump / Trench Sensor(s), Model: El Fill Sump Sensor(s). Modal: ❑ Fill Sump Scww(s). Model: tlo'h+btagmical Linc Leak Detector. Model; _ 0 `b _ U?(MochaMcal Una Leat{ Demeter, Model: ❑ ;Electronic Line LcU Detector. Model: _ _ ❑ Elcctmnic bine Leak Dctccwr. Model; �] Taunt Overfill l kltgh.Levol Sensor. Model: C] Tank Overfill i I3igh-1evel Sensor. Model: © other (specify equipment type and model in Section E ou Page 2). Q Other (spccify equipment type and modal in Sootion E on Pago 2), Tank ID: Tank ID: _ 0 In -Tank Gau¢intt Probe. Model: ❑ In -Tank 0auglag Probe, Modcl: 0 Annular Space or Vault Senor. Model: ❑ Annular Space or Vault Sensor. Model: El Piving Sump i Trench Smsor(s). Model: .... ....... ......... 0 Piping Sump / Trench Sensor(s). Model: , El Fill Sump Sensor(s), Model: 0 Fill Sump Unsor(d). Model: _ - 0 Mcchaniank Line Labs Detector. Model: l] Mechanical Linc Leak Detector, Model: 0 Electronic Linc Leak Detector, Model: ❑ Electronic Line IA& Detector. Model: ❑ Tarok Overfill / High -Level Sensor. Model: [] Tank Overflll i High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2), ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser IDI -- bis unser ID: 1 _, Diypcmer Contairuumt SCWr(a), Mock]: .��. 0i$pen' Containment Stnsor(a), Model: ❑ Shear Valve($). (] Shear Valve(a). Q i7ispemcr Containment Float($) and Chain(a). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: _ -- (gDisper= Contairuncnt Sanger($), Model: -�' W'Dispenser Containment Sensor(s). Model; at1 ❑ Shear Valve(s), ❑ Shear V&Ne(s). * Dispenser Contaminant Float(s) and Chaia(s), Q Dispenser Containment Float(S) find Utaln(s), Dispenser @: Dispenser ID: ❑ DispcnstrContaiament Sensor(s). Model: ❑ Dispenser Contaitnncnt Smsor(s), Model; ❑ Shear Valvo(s). Q Shear Valvo(s). © Dispenser Containment rloat(s) and Chnin(s). ❑ Dispenser Containment Float(s) and Chain(s). 'If the facility contains more tanks or dispensers, copy this form, include information for every tank and dispenser at utc luctlity. C, Certification - I certify that the equipment identified in this document was inspected/serviced in actordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verity that this information is correct and a 64e- lot Plan showing the layout of monitoring a Ipment. For any eqylpment capable of generatin such rep , I have also attached a copy of tho report; (check all that apply): System set-upfilar cry Technician Name (print): -Tony Pentanes„ _ _ Signature: , CeT�ifi�ntitln No.: V.R. A23680 ICC 5289227 -UT liicensc, _„.No.: A. 84$2$ Testing Company Name: U.S.T. Cona!liance Testing Inia. Phone No.: 208 695-4489 Testing Company Address: P.O. Box 580 Ceres, CA 85307 Date of Testing/Servicing: tint..nie _ era www:unidocs.org Rev. 01/17108 /2'd 22t7289117: 01 962-ZZ2S602 dDNt1I-1dW09 1S(1:W0dd 62:91: ST02-2-t,lUf