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Aug-31-04 04:53pm From-Gettler- Inc +9166311317 T-357 P 002/009 F-269 0 0 MONITORING SY STEMCERTM, CATION-MMIT For Use By AU:Jurisdictions Within,the State Of Ca gem in Wie=172FE _&+0 -ns, Audutrit.v Cired-z ffhaMef-6- tleatch.taid-,Sakj)rCode;:CWnp ter 1 6i-Division 3, Tx Tanpi&Cc fKeWdfitr If Diem than-OF'e:NKR]itur'mg7systemlconI garate certification or report must:be re ared.for eactr monitoring,system control panel panel,is,installed.at,tho Wlity,a I..e -em: the technician who, performs the work. A copy of this,.formr must.,be pmvided+t¢.the twk systemr omnerloperator_ owner/operator inust,subiwil.a col ty of+[Iris: fc>njj to,+tjw iocai.agency- regulating-UST SysteRI& withifff 3a days OU test d Instructions are printed on t1m.bacL if this page- A. Gefiefal'InfiIenuttioll" Facility Name; % Bldg_N0. LLD 9 Site Address;-/-6c5�1 t.-:;: City: l'o—rke�--rd 7ip-- Facility Contact Person: CosimmPhone.No.,: 207 ) Z2:Z Make/Model of Monitoring Systeur- 5,2so, Date,offes"g/Se,,iicing.. _Zj2_0j.2Y B. Inventory or Equipment'Ficsilcil/Certified Check thi-i2prupmate boxes to indicate spiecific equipment inspected/sez-viced: Tank ID: �E�7_ Tank ID:— I!;-- &= 13 In-Tank Gauging Probe. Model: 13 In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sciv*or(s). Model: 0 Piping Sump/Trench Sensor(s). Model: • Fill Sump Sensor(s). Model: L3 Pill Sump Sensor(s). Model; • Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector, Model: LI Electronic Line Leak Doo ctor. Model! U Electronic Line Leak Detector. Model; U Tank Overfill i High-Levcl Sensor. Model'— U Tank Overfill I High-Level Sensor. Model: $ir Dispenser Containment Sciisor(s). model: yrc 69,/7%1c-aoj ga-Dispenser Containment Seri Model: Vi?t4Y7990 • Shear valve(s). 0 SliearValve(s)- • Disperiw Containment Fluat(s)and Chain(s). 0 Dispenser Containment Floats)and Chain(s). • Other(sperify equipment type and model in Section E on Page 2). CI Other(specify equipmerittype and model in Section I-on Page 2). Tank ID: � T-7 V Tank ID: —7 2 • In-Tank Gauging Probe. Model! C3 in-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Modd: L3 Annular Space or Vault Sensor. Model- • Piping Sump I Trench Scimir(s). Model: L3 Piping Sump/Trench Sensor(s). Model: • Fill Sump Sensar(s). Model; U 1--ill Sump Sensor(s)- Model: L1 Mechanical Line Leak Delevior. Model: 13 Mechanical Line Leak Detector- Model: * Electronic Line Leak Dewor- Model: 13 Electronic Line Leak Detector. Model: * Tank Overfill/High-Level SensvY. Model! El Tank Overfill/High-Level Sensor. Model: eDispiaiscr Containment Sensor(s), Njodel- O'bispenser Containment Sensor(s). Model:_V9,t�1-7 99C 001 13 ShwrValvc(s). 0 Shear Valve(s)- 0 Dispenser Containment flull(s)amt Chain(s). Q Dispenser Containment Float(s)and Chain(s). I E3 Other(specify equipment tylve and model in Section Eon Pa2). 0 other(specify equipmwt type and model in Section Eon Page2). C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacture guidelines. Attached to this Certiji,wtion is information(e.g. manufacturers'checklists)necessary to verify that this information is con acrd Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also atraci. a copy of the(check all that appl.v): System set-up report; Alarm history report Technician Name(print); "dl &Q,_41 CerL/Lic.No.: Signature:: Testing Company Name, Phone No.: Page 1 of 3 05100