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0'-) ' 'I Lj MON*RING SYSTEM CERTIFIaTIO 1 For Use By 9/l Jurisdictions Within he.Smte of California .=1 ulhority Cited: Chapter 6.7, Health and SgfeN Code; Chapter 16, Division 3, Tide 13, California Code 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 sustain control p•mel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The.owner/operator nmst submit a copy of this form to the local agency regulating USRsystenms within 30 days of test date. A. General Information � L Facility Name: , /A1//�Nr /�ODl� `�` / 4wel, Bldg.No.: Site Address:ZY37,3 A( p✓y 99' City: Zip: 96Z70 Facility Contact Person:_`>I NGIy Contact Phone No.:C 2eff ) e-0-Z97Z Make/Model of Monitoring System: INWfV Date of Testing/Servicing: _/7,6/6:7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: TaPk ID: 8�r oG_T Tank ID: q I o c--f• ,7)n-Tank Gauging Probe. Model: /t7q(.f XIn-Tank Gauging Probe. Model: MQ� -U mular Space or Vault Sensor. Model: FI ❑ nnular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: /ALSiping Sump/Trench Sensor(s). Model: y L5 ❑JF'll Smnp Sensor(s). Model: EI Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: fdrMechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). To k ID• S`I 0 ST Tank ID: In-Tank Gauging Probe. Model: h ❑ In-Tank Gauging Probe. Model: ❑ nnular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model --�� ❑ Piping Sump/Trench Sensor(s). Model: ❑ ill Sump Seasons). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci equipment ty a and model in Section E on Page 2). ❑ Other(s eci equipment a and model in Section E on Pa&c 2). Di. enser ID: I -F 2- Di enser ID: � t— ispenser Containment Sensor(s). Model: N LS ispenser Containment Sensor(s). MoW ps Shear Vaive(s). Shear Valve(s).❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats)and ChaDi enser ID: + Dispenser lD: ispenserContainmentSensor(s). Model: k t.S ❑ Dispenser Containment Sensor(s). MoShear Valve(s). ❑ Shear Valve(s).❑ Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and ChaDis enser lD: S -i-� Dispenser ID: ispenserContainment Sensor(s). Model: I1 LS ❑ Dispenser Containment Sensor(s). ModShear Valve(s). ❑ Shear Valve(s).❑Dis enser Containment Floats)and Chain(s). ❑ Dis enser Containment Floats)and Cha *Ifthe 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 equii ent. For any equip rent capable of generating such reports,l have also attached a copy of t e report;(check at)that apptt): �System s t- p his tor report Technician Name(print):�l.( M[-An Signahu Certification No.: l l $3 License.No.:_ 0,1- 1676 6 .1 Testing Company Name: fFOenQ — IESj PhoneNo.:(209 ) 7E44-0112 Site Address: 7,43Z3 /Y • Wy Date of Testing/Servicing: Z6/0:7- .. Monitoring System Certification Page 1 of 03/0t D. Results of Testing/Servicing