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MON&RING SYSTEM CERTMATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safery Code,-Chapter 16,Division,, Thle 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A sevarate certification or recon must be Drevared for each monitoring system control vanel by the technician who perforins the work A raspy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating CST systems within 30 clays of test date. A. General Information Facility Name: ;'JA f L 5 L) 'QLtct7 4 Fec P Bldg, No.: Site Address 5 T, City:E'5CALe rs C-4 Zip: 9 5 3-2� FacilityContact Person: C N A C&C -f-FfaA(A5 Contact Phone No.: -2( a I ) q3'3-,7(--7y Make/Model of Monitoring System G't L lel t9 2 CD Cif e Date of Tesdag/Servicing: B. Inventory of Equipment Tested/Certified Cheek thea ivp�ate boxes to badicece ui went serviced: Tank ID: Ta9jc3D 171ESEZ E Irj-.Tank Cmngi ig Ptnbc. Model: .NAC- -2-- ' 'IntTank Gauging Probe. ModeL-/r"tyi<---4 Annular Space or Vault Seasor. Model:O.4o;L54 11 V`f eve. ❑ Annular Space on Vault Sensor. Moder SAA 21Pping Suatp I Trench Sensor(s). Modcl;p -c's.S4a.Gu^uoib Crfiping Sump/Trench Seasor(s). Mcdel:/74c:i-3°Idccoc iO CI Fill Sump Sensor(s). Model: 0 Full Sump Sensor(s). Model: R'blechanial Line Leak Detector. Model: t I b-eSX1 ❑'Mechanical Line Leak Detector. bfodd: C 5 4: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. model: El Tank Overfill f High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(svccfy equipment and model in Section E on Pa 2). ❑ Other(specify equipment EyEE and model in Section Eon Page 2). Tankm: Z- S•CPtE uNC�G�4 t7E0 TankW- trin-Tank Ganging Probe. Model: -4t.4G--Z ❑ In-Tank Gauging Probe. Model ❑ Anular Space or Vault Sensor. Model: l4/ f ❑ Amutar Space or V mh Sensor. Model: O'Piping Sump/Trench Sensor(s). Model:40,4 QW33.t C�Zj)o Cl Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sections). Model (3 Fill Swnp Seusor(s). Model: l2'fvlechanical Line Leak Detector_ Model: f 16- j k. ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line leak Detector. Model• ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill i Higb-Level Sensor. Model: ❑ Other fs ec' omem type and model in Section E on Pa 2). 17 Other(sSguipmcnr=and model in Section Eon Page 2). Dispenser ID: I-2 Dispenser to: Cl Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: C'i'Shear Valve(s). 13 Sher Valve(s). Mr'bisinnser Contaiomein Float(s)and Chain(s). U Dis Containment Floats)and Chain(s). Dispenser.ID: -3-`F Dispenser ID: ❑ Dispenser Conmhhmeat Sensor(s). Model: 0 Dispenser Containment Sensm(5). -Model: alshear Valve(s). 17 Shear Valve(s). 3'bispenscr Containment Fioar(s)and Chain(s). E3 DisEEnser Containment Float(s)and Chain(s). Dispenser W: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Seasot(s). Model: Fbe--v,lve(s) Ca Shcar V al r(s). ODspenser Containment Floats)and Chain(s). ! ❑ Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this form Include information for ever; tank and dispenser at the facility. C. Certification-I cer(ity that the equipnoenk iden6liied in this document was inspeeiedlmrh iced in aceordmee with the nlanutaekutxr5' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary, to verify that this information is correct and a Plot Plan showing the layout of monitoring egw�gment For any equipWent capable of generating such reports,I have also attached a copy of the report;(check all that apply): 0-System set-top UA41nn histo }'e rt Technician Name(print): it/t,J i 1.1 L, iGf/C f3,h R a Signature:- zlj�4 LjL- Certification No.: License.No.: Y6 ff 8 l, c% Testing Company Name: e- 4,4,4e N'I ohJ feskz(sio,^) Tt`1NK -ki zrl it-L- Phone No.:( z Site Address: I$'77 p tE5E2 Lw, Sq c 44 m Eq.--�b f C-4 Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification