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` MOWORING SYSTEM CERTOCATION <br /> rW Use By All Jurisdicttont Within the Slate o C alffornia <br /> Authority Cited: Chapter 6.7, Health and Safety Code,' Chapter 16, Dtvt.Ylon 3, Titre 13, California Cade of Regulations <br /> This form must be used to document testing and servicing of monitoring equipment. A separate rettitl atinn or r n ri m Ict <br /> RIE1�xf k stacit monitorine cyc! m control D net by Oto technician who perfonns,[he work. A co <br /> to the tank systtm. rovic <br /> own ate. ator, The owner/operatormust submit a copy of Ibis,forrim (o',the.localyagencyof sregulating form sUSTt be s ysu; <br /> within 30'days of test date. <br /> A. Generalr�nforination <br /> Facility Name:, A-, 6r- . S ung u 5 <br /> Site Address: tJ90S�i,4_k4frQUY--IW-L,,� Bldg.,No,: <br /> City: 5 �bcic �v r Zip: <br /> Facility Contact Person: _rl�io w c s T(I l rq <br /> blake/Mode1 of Monitoring System: Vet�Y— u Fr11�5 3 Contact Phone No.: �U 87 — <br /> Sc� ( ) l ss v <br /> B. inventory of Equipment Tested/Certifled Date of Testing/Servicing: Zl j <br /> Cheek the a _ .... .-.•..•. . <br /> rice boxu to Indicate a etint a ul menf ins eetedhery&ed; . <br /> Tank ID; 1— aL,4- �uL.(,- - <br /> O 14-Tall-Gauging ProbeModel Tank ID: L <br /> O 1n Tank GauW.'sUlu M <br /> •Model: <br /> { Amul Space or Vaull Sensor, Modd: rl 4 el3 g p_'110 <br /> Vlr—PLaa� )� \phnular Space r Vault Sensor. Model: U R <br /> Pvp(ng Sump/Trench Sy�I sor(s). odel: "���Y �'v}' : 320-40,11 <br /> e°c�.r—ytov -(.3, eA_c.,k� d t�13`s0—2.08 F• piping Sump/Trench sensor(s). <br /> O Fi11aumpScn <br /> Model: <br /> sor(s). odci:b�.`243ryt� _zU� <br /> O Fill Sump Sensors) �' - Y`wh <br /> O.Mechanical L neI Leak Detector. Model• Model: , <br /> O Mcchanical—Une Leak Detector, Model: <br /> OElectrunicLine—Luk Detector. Model; <br /> O Electronic.Liar Laa p(or. Model; <br /> O Tank Overfill/High-Level Sensor.- <br /> Model: ❑ Tank Overfill/High-Level Sensor. <br /> O Others it a vi men t and model in Section E ompe a 2). O 0(hcr(s it equip Inent tv a and model in Secl on E bn pace 2)- <br /> Taak ID: �3 V� C...G . <br /> la-Tank Gauging probe, Uk AD: <br /> v Model: .' O -Tank Gauging probe. <br /> t aular pace orr V�Sensor. Model:Dl1 - Model: <br /> 'e r '�3�L0-t{U`I 11 Annul SP I tace or Vault Sensor. Model: <br /> p�°gam m,Y ell Se orfs), Model: 0 7etg3fta Z p <br /> e� > 0 <br /> O Piping Sump ench Sensor(s). M <br /> Flo Sump Setuor(s). Model: - ' <br /> A MahanlcalLine Leak Detector. Model! ' 0 Flll Sump.Sensor(s). <br /> Model: <br /> 0 Mtchwmical Line C Detector.. Model: <br /> 0niUO c��Duector. Model: <br /> O Efectroni ne L- ID <br /> etector, <br /> O Tank p High-Level Sensor. Mo <br /> Model: O T Overlill/ i ligh-Level Sensor, <br /> O Other is ecif ui mem t and model in Section F,on pa e 2). Mode, <br /> Ispeaser ID: ) Olhcr(s if ,e ui mcnl tXpe and model in Section E on Pa <br /> 0 er Containment Sensor(s), Motlel: isPenser ID: <br /> ❑ Shear Va 5. enser Contalmnent Sensor(s). <br /> 0 D Model: <br /> ser Con in c, Fludt sl and ChainW. 0 Shear Vit ( , - <br /> Dispenser ID: O DispensuF CU IairiitJen! r:)pa••_• and Chain( <br /> s) <br /> O Dispenser Containment Sense Model: Dispenser ID: <br /> O Dispenser Containment <br /> O Shearvalve(s). <br /> O D- nser Co to nment Float s and.Chain s , O Shye(s) <br /> Dlsgeaser O Dis cnser Cental rltcnt Float s' and Chains ,,_ <br /> O Di ercontalnmcni Scnsor(s), Model: Dispenser ID' <br /> Va14e(s) O Dispctt5 Contalnmcnt ScnSaris). " <br /> Di User Cott t<1ode1: <br /> fafnmcm Floats and Chain s . �S cac Valvc(s� <br /> .1 User <br /> the facility contains more Ianks or dlspensers, copy this t� )IslLcwcr Containment Floats and Chain s). <br /> form. Include information for ev <br /> Cry tank and dispenser at the facility. <br />