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IVIVINFIX)JUNG SYSTEM AuthorityFor Us AIIJutisd' - �'tCEI TIFICr?w Cited: Chapter 6.7, Health and Safety Code; Chapter 16 Division the State 3 Title 23, California Code o Re This form must be used to document testing and servicing of monitoring for each OfRegulations monitorin s tem control ane] by the technician nn8 equipment,A s system owner/operator. The owner/ erator must submit performs the work. A co'rad�rtrficanon or ort must be r aa red of test date. °p PY of this form must be provided to the tank PY of this form to the local agency regulating UST systemsA, General within 30 Facility Name: P-G; -SDGe78 Site Ad dress: 40 -40 W,--ST Ld4yLlr Bldg. No..- Facility Contact Person. City: �:r0CKTdrU Make/Model ofMonitorin � �/�!�Gr Zip: y'Sy gSystem. l/C/S ��bTContact PhoneNo.: Zpq [s0z - B. Inventory of ETLS —"7O�`� Equipment Tested/Certified Date of Testing/Servicing: Check the a ro nate boxes to indicateOTank s ecific IDW meat fns ed/serviced: Q'In-ank- Milli C/FII f>YAnnulaz u8m8 Probe Model:�[�� Tank ID: -SL Space or Vault Sensor. Model: n79t/? Whi-Tank Gauging Probe. grPiping Sump/Trench Senso s. 9 0 yin B'Annular S Model:.. (/R ❑ Fill Sump Sonsor(s). K) Model: 079N yU_ R pace or Vault Sensor. Model: 0 Mechanical Line Leak Det Model: 'niping Sump/Trench SensoKs) Model n 9�-yid Detector. Model: Ll Fill Sump Sensor(s). 9439 p_2Oc�. (li(Electronic Line Leak Detector. Ll Mechanical Model: f�Tank Overfill/Hi Model: I Q Line Leak Detector. Model:— Other gh-Level Sensor. Model:_n B Electronic Line Leak Detector. Tank ui ent and model in Section E on pas - WT Overfill/High-Level Sensor. Model: Of'W / mss" Q lye o ��' i meet a and model in G� 8mg rrobe Tank ID: Section E on Pa e 2 . WAnnular S Model: pace or Vault Sensor. Model: p'7q c/ O In-Tank Gauging probe. Ll Fill Sump/Trench Sensor(s). Model: 9 D-y7 n ❑ Annular Space or Vault Sensor Ivlodel:-- ❑ Fill Sump Sensor(s). -gZgy3 Model: Meeh Model: d ZA9 O Piping Sump/Trench Sensor(s). Model'— anical Line Leak Detector. Model: ❑ Fil]Sump Sensor(s). 17 Electronic Line Leak Detector. ❑ Mechanical Model: GYrfank Overfill/Hi Model Line Leak Detector. Model: Other High Sensor. Model: t7 79 y Electronic Line Leak Detector. —� eci ui went and model in S 90 y2O O T�Overfill/Hi Model: Dis enser ID: echon E on Pa e 2 . O Other High-Level Sensor. Model:� �4, /o a and model in Section— ispenser Containment Senso s . Dispenser ID: � � � on P e 2 . Shear Valve(s). �� K ) Model: 079y 3�qp �'Di U Di ser ContainmentSpenser Containment Sensor(s). Model: 0 Floats and Chain s . 0 Di set v s . p/o 795'.3R�-Za Dis user ID: �) K/ �� ,�.,�� 'Z ❑ Di ser Containment Flea s and "a Lispenser Containment Sens s . Z Dispenser ID: Chains . 'Shear Valy s . ) Model: p 7g y rp_ O Di e( ) e'7`7t�.1 �� ❑ Dispenser Containment senso s . Model: ser Containment Floats and Chain s . ❑ Shear Valve(s). Dispenser ID: U Di ser Containment Floats and Chain s Ll Dispenser Containment Sens Model:Model: Dispenser ID: ❑ Shear Valve(s). --�_ ❑ Dispenser Containment Senst 1 1 Model: ODi er Containment Float s and Chain s . 0 Shear Valve(s). "I£the facility contains more tanks or dispensers,co O Di ser Conta nnment Flo s and Chains . sP copy this form. Include information for every tank and dispense,.at the facility. C. Certiiees. Acta _I certify that the equipment identified in this document was inspectediserviced in accordance with the manufacturers' correct an Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equinmeat. For any egWpment capable necessarygeneratingoverasuch reports, attached a copy of the re rt;(check a/t that a I I Technician N (print): �py�' ystem net-up fd`,�Istory report f have also Name Certification No.: Signature: y ,&tit HZDZS?i-I License. No.:_ y 9 A7 Z 1 45:Zs2 Testing Company Name:fbQ141B1,6Q �(�k o Sow d�7J 113 4 t 7 UT Phone No.: y3 7 � Site Address: iYO Date of Testing/Servicing: lonhtoring System Certification Page 1 of 3 03101