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i MON* INN SYSTEM C.ERTIF TION f-L� � Fov,l r• Use Bl1 uriseliclions Within the Stwe gl'Culilurnia -I ulhorila-C'ilvd: Chaper 6.7, Neallh aml&tf,lv Cotle, ChalVer 16, Division 3, Title 23, California Coele of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or refsort must be prepared for each monitoringsystem ntrol panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/Rperator: The .owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneralInformatiorl Facility Name: V I Bldg.No.: Site Address: i 4/4,e-rK-e ij City: '!ST4w-W--Tena Zip: 9-5-77— Facility Contact Person: . o Contact Phone No.: Make/Model of Monitoring System: X50 Date of Testing/Servicing: EA /QE B. Inventory of Equipment Tested/Certified Checte gieappropriate boxes to indicate s eciGc et ai�nt inse cocci/serviced: T ank T Tank ID: --'r Gauging Probe. Model: /� 'Jain-Tank Gauging Probe. Model: tt�J�AL 6v f Space or Vault Sensor. Model• nular Space or Vault Sensor. Model•ump/Trench Sensor(s). Model: ff Piping Sun7p 1 Trench Sensor(s). Model: �a�8 0 Fill Sump Sensor(s). Model: ❑ II Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX,r t� Mechanical Line Leak Detector. Model: FX l ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Pa e 2). - ❑ Other(specify a ui ment t e and model in Section E on Page 2). Tan c ID: a C-' Tank ID: I Tank Gauging Probe. Model: /� LI In-Tank Gauging Probe. Model: ,0�snular Space or Vault Sensor. Model: D ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: c-,74V ❑ Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: OXY r V ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment type and model in SectionE on Pae 2). ❑ Other(specify ecui meat type and model in section E on.Page 2). Dis7nser ID: 1 `f- 2 Dispenser ID: "� 4 Dispenser Containment Sensor(s). Model: 08 O Dispenser Containment Sensor(s). Model: Z o8 ISI Shear Vnlve(s). A-Shear Valve(s). ❑ Dispenser Containment Float(s)raid Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D: 4- sf Dispenser ID: ffl Dispenser Containment Sensor(s), Model: Z08 ❑ Dispenser Containment Sensor(s). Model: •d Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 54-(, Dispenser ID: J&Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: &I-Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and *If the facility contains more 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. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any cqui ment capable of generating such reports,I have also attached a copy of I the report; (check all that gppdv): xSys a -u Inrm history report ' Technician Name(print): lW V tmr,n Signature: lla3 cc -a 5z1r.33x.7 -07- Certification No.: License.No.: r3 . el" -/(6242 Testing Company Name: A 94x i)A -,Les r Phone NoJa 0l)'74-1 - 0&.2- Site Address: f. C'4/AAV�Et 01A- Date of Testing/Servicing: 5/0 Y,f07- f Page I of 3 03/01 Monitoring System Certification B. Results of Testing/Servicing