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Sep . 2 . 2003 9 47AM ' ^ SERVICES No 1524 P . 2 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdiction:Within the Smte of C20mLa Authority Cited Chapter 6.7,Health and Safety Code, Chapter 16,Division 3.Rte 23, California Code of Regulations This form mast be used to document teatiog and servicing of monitoring equipment.A senarate=dficatioa St revort mot he Roared lot each Qwolaritre svatem comrol oaael by the technician who perforans the wodk. A copy of this form m>et be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the oral agency regulating UST system within 90 days of test date. A. General Information t�lZaS Facility Name: Ci Rx l E k Bldg.No,: Site Address: !'1pgPe Gar*T blL�Ct!)E City: LATti/2-0 Zip; 9.5-33 0 Facility Contact Person: Contact Phone No.: hlake/Model of Monitoring System: V FELI-a667- Z74S-3.50 Date of Testing/Servicing: 8J Z4/*,3 B. Inventory of Equipment Tested/Certified Check the apprviaripte Isoaes to Indicate spheiffe Malpiritat 1 ehflndvlad: Tank tD e 7 Tank IM - 91 In-Tank Gauging Probe. Model: M Ar&/ Taak Gauging Probe, Model: Annular Space"Vault Sensor. Model: Annular Spas or Vault Scnsor. Model; Piping Sump t Trench Sensor(s). Model JKPiping Sump/Trench Seusor(a), Model: Fill Sump Semor(s). Modct U Fill Sump Samor(s). Model: WMeelwrical Use Leek Denector. Model: )(Mechanical Line Leak Detecwr, Model: 0 Electronic Line Leak Detector. Model: O P.learonic Line Leak idecter. Model: 0 Tank ovetfill/tQgh-Level Seaver. Model: 0 Tank Overfill/High-Level Sensor, Model: 0 Other(specify cquie=t type and model in Section E on Pa 2). Q Other(SWW i nt and model in Section E on Page 2), 'rank ID: Tank net 0ht-Tank Gauging probe, Model El Io-Tank Gauging Probe. Model: 0 Annular Space Or Vault Soarer, Model: Q Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Seas;Ws). Model; 0 Piping Sump/Trmch SemWs), Model: 0 Fill Sump Soosor(s), Model: 0 Fill Sump Soasos(s). Model: 0 Mechanical Late leak Detector. Model: L1 Mechanical Line flak Dciocmr. Model: 0 Ele oic Lime Leak Detector. Model: 0 Electronic Linc Leak Detector, Model: 0 Tank Overfill t High-Tavel Sensor. Model: Cl lank Overfill/High-l< el Sensor. Model: 0 Other(specifv ccruivencut type and model in Section E on Pago 2), 0 Oster mcnt tm and model in Section E on p c 2. ui :vefVICOsv) l Dispenser ID: tainmcot Sensor(s). Madel: 0 Diapcnaer containrreat Sensot(s). Model: Shear . Shear VWve(a), Disotai�rnt Floes add Chain(s). Dis Containment Float(g)and Chains)_ Lympenser ID: Dispenser ID: 0 Dispenser Containment Seasor(s). Model: 0 Dispenser Containment Seosor(s). Model- El Shear Valvc(s). 0 Sheer Valvc(s). 17 Dispeow Conuinuient Floats and Chain(s. 0Dispenser Containment Floats and Clhaia(b. Dispenser ID: INspeiaer ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shcm Valve(s). f7 Shcar Valve(s). UDispcmcr Containment Floats and Chain(s)- 0 Ditperiacr Ccatainntcnt Float(s)mal Chain(s). 7f the Facility contains more tanks or dispensers,copy this four. include information for every tank and dispcascr at the facility. C. Certification-I certify that the equipment identified in this document was Inspected/serviced In accordance with the mannmcrihrer's' guidelines. Attached to Itis Certification Is information (cg.numuNctunrs' checklists) nccensary to verily that this information is correct and a Plot Plan showing the layout o(monitoring equipment. For any [Hent capable of generating such reports,I have also attached a copy of the reE (check of E ply a WSystem s p Al t'l>�Is107 trparj' TecbnicianNam((print): C IkRL d Signature: � L---��p�y� / oQ Uerti(ication No.: Ucense,No.: !w— cC�t-�qq�. /////,�,''rrC,,P--�L 7 Z Testing Company Name: LC Sfr:--yt/ as Phone Nn.:�� _T'I'T /706 Site Address: 1(p Lt70 C4m9fl!-6G-E - /.-A-rh¢njo Date of Testing/Servicing: q3 Page 1 of 3 allot. Monitoring System Certification