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JUL 2 € ZG08 MONITORING SYSTEM CERTIFICATION ENVRONMENr HEALTH ror Use Br Al/Jurisdiction 1171hin the Sime gfC'alijornia Rf ThFRU��ES Aulhorf/y('iced: Chapter GJ, Health nnd.S'yji•ry Code; Chapter/G, Division 3, Tille 23, Ca/ijirrniu Cndc�t�f c �a n Turas 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 pmtel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator []last submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information t _ Facility Name: /� Bldg.No.: Site Address: City: Py,Gnn'7(T� Zip: Facility Contact Person: �� Contact Phone No.: ( 2.0:�l ) ?227 78N-) Make/Model of Monitoring System:T Ne.(>1 7`b IDOD Date of Testing/Servicing:0-5-05—1 a B. Inventory of Equipment Tested/Certified Chech thea ro riate boxes to indicates ecific a ui ment ins ected/serviced: Tank ITank ID: Vic( Ai In-Tank Gauging Probe. Model: M1)(, W In-Tank Gauging Probe. Model: M A 6 *Annular Space or Vault Sensor. Model: F IS Z Annular Space or Vault Sensor. Model: P Piping Sump/Trench Sensor(s). Model: 111_5 Ef Piping Sump/Trench Sensor(s). Model: l 1LS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: lr Mechanical Line Leak Detector. Model: 1_17 2000 0 Mechanical Line Leak Detector. Model:�F C1 Electronic Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: 1 Tan d In-Tank Gauging Probe. Model: Mtdb ❑ In-Tank as 'ng Probe. Mod El Annular Space or Vault Sensor. Model:__— ❑ Annular Space or It Sensor. odel: J Piping Sump/Trench Sensor(s). Model: UL-S ❑ Piping Sump/Trench Se Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). ode]: 0 Mechanical Line Leak Detector. Model: 1>Z000 ❑ Mechanical Li+ eak Detector. Mo e . 0 Electronic Line Leak Detector. Model: ❑ Electroni me Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ T verfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). Q Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 1 b Z Dispenser ID: 7 ( Qi ❑ Dispenser Containment Sensor(s). Model: ULS ❑ Dispenser Containment Sensor(s). Model: ULS El Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Flont(s)and Chain(s). U Dispenser Containment Float(s)and Choin(s). Dispenser ID: s I Dispenser ID: ❑ Dispenser Containment Sensor(s). Model UL ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: i Dispenser ID: ❑ Dispetmer Containment Sensor(s). Mode]: UL,S ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(s). ❑Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). •II'the facility contains more tanks or dispensers,copy this form. Include information every tank and ispenseerrrya)' the facilit �[�g,,y/'7 try. � ' `ir d C. Certification - I certify that the equipment identified in this doEumen hYn§" �i p fQd/se teed in c orilan a inth 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 an equip tentapable of generating such reports,11 have also attach99d a copy of the report•, (check all that apply): �Syst m t-t la m history report Technician Name(print): Z ri/ /�i lamp Signature: /} _qW Certification No.: 61o((`s License.No.: 90 -1143 /I Testing Company Name: I''I `mr•[Z{��p ex No.:� Oq �74 —0/), Site Address: a v��23 N k11A)(r 06 Date of Testing/Servicing:D5 P /—i,) .- '• Page I of . . 03/01 Monitoring System Certification - D. Results of Testing/Servicing