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Apr 22 02 04: 46p A SPANCS JET CENTER (2 9) 963-4710 p, 3 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California .4uthoriry Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of.Regulalians This forth must be used to document testing and servicing of monitoring etluipraent.urate cErti,ficatioa or rtttsort must be l;t,feOW For each troniloring rstem_conrrol narL by the technician who performs the work. A copy of this faun must be provided to the tank systeru owatr/vperator- The owner/operator must submit a copy of this form to the local Agency regulating UST systems within 30 days of test date. A. GeneralInformation .� Fac:litw�arrre: Bldg.No.: Site Address, City: zip: -�r+( Facility Contact Person: /?991). � C ... _--, —-- Contact Phone No,:{ p_ } � h "/,5's-n Nlake:•lfodel of Monitoring System: VI W)rV- - e0k� _ _ - Date of Testing/Serviciog: -3 1/%91 0Z B. Inventory of Equipment TestedlCertified Check the appraerlate bases to Indicate! eelfle equipment fns ectedlurviced: ,T�li m: Tank IM 0'1n-Tank Gauging Probe. Model: 10ftre:"?" A a In-Tank Gauging Probe. Model; >t�>sf.' 00- 51 ,annular Space or Vault Sensor. Model. t`_..._.-. 't[ _.. ..._._-__ 5L Annular Space or Vault Sensor- Madel: +< t r Sd Piping Sump/Trench Sensoi(s). Model: ��_ i 'tai Piping Sump/Ttench Sensor(s). Model: yealite ia*,r I Fill Sump Sensor(s). Model: "IA d-Flll Sump Sensor(s). Model: �'- � %le�chanical Line Leak Detectot. Model. i Z^TrCk[%' 9 Mechanical Line Leak Detector. Model: It+1 gels `> Electronic tine Leak Detector. Model: AYA D Electronic Line Lcak Detector. Model: _ �/r{ ® Tank OverflIl t High-Lcycl Sensor. Madcl. yLcel rw_ -r - 0 Wank Overfill/High-Levcl Sensor. !Model: 4at$16e a ire.*" ❑ Otho(s fv equipment a and model in Section E on Pae 2), 0 Other s ecl(iy a ui rnenr type and model in Section E on Pae 2)- Tank ID: Tank ID• 3 In-Tank Gauging Probe. Mcidel E'art xco•r ❑ In-Tank Gauging Probe. Model: ?ranular Specc or Vault Sensor Modct: 0 --- ❑ Annular Space or Vault Scnsor. Model. 9 Piping Sump/Trench Sensor(s) Modcl �t` 7� _- ___ U Piping Sump t'l-rench Sensor(s) andel! M•Fill Sump Sensor(s). Model: _C.^_— C1 Fill Sump Senanr(p). Model: $a Mcc:hanical Line Leah Detectot ]clodel: T 0 Mechanical Line Leak Detector. Model: a F ecrronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: !*Tank Overfilt/High-Level Sensor. Model: Veyhrti' .'eco ❑ Tank Ovcrflil/High-Level Sensor. Model! ❑ Other(s tti if;r ui meat[ e and model in Sccrian E on Page 7). 13 Other( self a ui cheat t c and model in Section E an Pae 2). Dispenser iD. _T Dispenser ID._ D Disocn]cr Contammcnt or ). lode]: ❑ Dispenser Contairinrent Se/) d ❑ Shearvah-e(s). 0 Shear Valve(s).� Di,eraser Containment F t( and Chsiurs). ElDia enser Comainme FioChain(s)_ Dispenser ID: ' A I _ Dispenser 11):_ _ ❑ Dispc tscr Containmc Model: C3Dispenser Containment 5 t3 Shear Valvc(s). - ---_-_-, p 5hcar Valvc(s). ❑ Disoenser Containmc Float(s)and Chain(s). ❑ Dis crtser Contain [ ( art Chain s). Dlspeaser MD Dispenser[Ia: ❑ Dispenser Containment Sensor(s). Modcl _ 0 Dispenser Containment Stnsor(s). Model:. '0 Shear Vahe(s)- ❑ Shear Valve($). ❑Disaenser Containment Float(s)and Chains Ll Di4penser Conumment FloaL(s)and Chain s). `If the facility contains more ranks or dispensers,copy this form, Include infon:rwrinn for every tank and dispenser at the facility. C. Certifleatfen -I certify that the equipment idcnlifted IQ this dntutnent was Inspected/serviced In accordance with the manufacturers' guldellnes- Attached to this Certification Is Information (e.g. manufacturers• checkilsts) necessary to verify that this Information 16 correct and a plot Plan showing the layout of monitarlup equipment. For any equipment capable of goneratia=such reporh,I have also ' artached a copy of the repo (c tck all Thar apply): 13System set-up 10 Alarm ep t Technician Name(print): '.L t z Z— _ - -- Signature: �- Ccrtificadou No.: '� � _ License. No.: Testing Company Name, Phone NuJ v - 7&- Site Address: Date of Testing/Servicing:sell_/�1 p3/pi �Iotlituriag System Certification Page I of 3 / - � %� .e *iso