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MONITORING SYSTEM CERTIFICATION For Use Bi,,4 l Jurisdictions H tthin rhe State afCalifornia AuthorityCited:Chapler 6.7. Health and Safety Coal Chapter 16, Diririon 3, Tide 23. California Cale of Regulations This form must be used to document testing and servicing of monitoring equipment..A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information C _ Facility Name: tgo0-6&'A' C-44re'J?-Dw-' AST ms's O 'y �G Bldg.No.: Site Address: I08tF8 IV, y City: smnr, -rc+J Zip: '70,!>-"2— Facility 7"S-"2Facility Contact Person: Contact Phone No.:( MakeJModel of Monitoring System: Auma!&miaDate of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: $ Tank ID: T11 f4yE_V iB In-Tank Gauging Probe. Madel; /y y IN Annular Space or Vault Sensor. Model: Hes In-Tank Gauging Probe. Madel: r au a sot. Model: Piping Sump/Trench Sensor(s). Model: G(tfj �S Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U Fill Sump Sensor($). - Model: SI Mechanical Line Leak Detector. Model: K- I t9 Mechanical Line Leak Detector. Model: G .ld ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: Q Other($ ci ui ment and model in Section E on Pa 2). ❑ Other(specify ui merit and model in Section E on Pa a 2). TanklD: - Tank to, 0 In-Tank Gauging Probe. Model: /y/L/' - U in-Tank Gauging Probe. Model• )n Annular Space or Vault Sensor. Model: f.(LS ❑ Annular Space or Vault Sensor. Model: - 0 Piping Sump/Trench Sensor(s). Model: t4i S Piping Sump/Trench Sensor(s). Model; 13 Fill Sump Sensor(s). - Model: ❑ Fill Sump Sensor(s). Model: fi Mechanical Line Leak Detector. Model: 9�D� 12 Mechanical Line Leak Detector. Model:Kat- %J ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: - - ❑ Tank Overfill/High-Level Sensor. Model: - 0 Tani;Overfill/High-Level Sensor. Model: El l Other(s ci equipment ty a and model in Section E on Pae 2). ❑ Other(s eci a ui ment a and model in Section E on Pae 2). Dispenser ID: l i-b Dispenser ID: - ,S+(o ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor($). Model: Ad Shear Valve(s). Shear Valve(s). 4I Dis nser Containment Float($)and Chain(s). Dispenser Containment Floot(s)and Chain(s). Dispenser ID:_ cf' - - Dispenser ID:_- T-i- $ j7-Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: A$ Shear Valve(s). IR Shear Valve(s). Dispenser Containment Floats)and Chain(s). ADispcnser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 13 Dispenser Containment Sensor(s). Model: ❑ Disperser Containment Sensor(s). Model: C3 Shear Valve($). _ Q Shear Valve(s). ❑Dis nser Containment Floats)and Chain(s). 13Dis nser Containment Float(s)and Chain($). *Irthe facility contains mom tanks or dispensers,copy this to=. Include information for every tank and dispenser at the facility. C. Certification - 1 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 equipment capable of generating such reports,I have also attached a copy of the report(check all that apply): A Sys y Alarm history report Technician Name(print):Z4 Al! p Signature: '� l Certification No.: 3 YCC 52¢332 ^UT License.No.: Testing Company Name: T�s� Al. hone No.:�',jO9 Site Address: e7 wY �1 Date of Testing/Servicing: 2 / /% /O� Page] of3 - 03laf '-Monitoring System Certification ( - D. Results of Testing/Servicing d r a