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Authority Cited: Chapter 6.7, Regulations • Appendix VI Ll MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California h and Safety Code; Chapter 16, Division 3, Title 23, California Code of This form must be used to document test ng and servicing ofmonitoringequipment. A separate rm mustion or provided rt must be to the tank prepared ar mfor each monitoring system control panel by he. technician who performs the work. A copy of owner/operator. The owner/operator mu submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GenInformation p Facility Noma• 63Q'-6 Site 1 p (p Facility Contact Per -nn! Make/Model of Monitoring B. Inventory of Equipment Te Check the appropriate boxes to Tank ID: CJ T ©K— ► In -Tank Gauging Probe. M [� Annular Space or Vault Sensor. M lA Piping Sump / Trench Sensor(s). M ❑ Fill Sump Sensor(s). N J• Mechanical Line Leak Detector. N ❑ Electronic Line Leak Detector. h ❑ Tank Overfill / High -Level Sensor. h ❑ Other (specify equipment type and mod City: Bld/g, No.: J/Ot roA Zip: 9s Contact Phone No.:6 - J�t:ty� 12cc"T "TLP -'"r— Date of Testing/Servicing: S'Z 'w I licate specific equipment inspected/serviced: Tank ID: YS -1 OGS Tank ID: ff 1�1 P� �1 ® In -Tank Gauging Probe. Model: HhGf I el: y p9 IN Annular Space or Vault Sensor. Model: el: 7� g ® Piping Sump / Trench Sensor(s). Model: el: ❑ Fill Sump Sensor(s). Model: lel: 499 (-b-zp«:> A. Mechanical Line Leak Detector. Model: C19 L )2eX� lei: ❑ Electronic Line Leak Detector. Model: lei: ❑ Tank Overfill / High -Level Sensor. Model: fel: ❑ Other (specify equipment type and model in Section E on Page 2). in'Section E on Page 2). Tank ID: YS -1 OGS Model: In -Tank Gauging Probe. M del: Annular Space or Vault Sensor. M el: 9 7 D ® Piping Sump/ Trench Sensor(s). M del: ❑ Fill Sump Sensor(s). M del: $1 Mechanical Line Leak Detector. MI del: 9q L,D2ocx3 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 z. ❑ Dispenser Containment Sensor(s). W9 Shear Valve(s). ® Dispenser Containment Float(s) and Dispenser ID: S -* `f ❑ Dispenser Containment Sensor(s). [g Shear Vatve(s). I8 Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ElDispenser Containment Float(s) and Chain(s). 'If the facility contains more tanksor dispe ser-, copy Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or vault Sensor. Model: ❑ Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in E Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Model: Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Ch; form. Include information for every tank and dispenser at the C. Certification - I certify that the JNimmo dentified in this document was Inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Ceinformation (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the laitoring equipment. For any equipmentAlarm history o le of generating such reports, I have also attached a copy of the report; (check all rhapply): lai System set-up ® ryj� ■ Signature: Technician Name (print): Zane License No: #04-1676 ICC #5263 27 UT Certification No.: 1183 Phone No. 209 744-0113 Testing Company Name: AFFORDA- EST Testing Company Address: 416 2" S REET GALT, CA 95632 Date of TestinalServicinq Z f D 9 2/21/07 Monitoring System Certification Pagel of 4 i