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Dec 21 2007 11 : 48AM HP LASERJET FAX P • 4 MONARING SYSTEM CERTIFICATION For Use By AllAwudictions WUhin the State of California Authority Cited: Chapter 6.7,Health and Safety Code, Chapter 16, Dn tsion 3, 7Yt a 23, Caltfornta Code of Regsdations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report meat be]t=arexi for each monitoring system control panel by the technician who performs the work- A copy of this loom 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 Facility Name: PU . S779CAMP10 S t }t/ Bldg.No.: Site Address: 4090 City 3 "rocnmx-u Zip: 9,S20r/ FacilityContact Person _ /W Contact Phone No.:(?Q4 ) G07- -70,,? Makdmodel of Monitoring System �D,?K Afl07- TLS -3.50 Date ofTestmtin Testing/Servicing: � ing: B. Inventory of Equipment Tested/Certified Check the appmoriate bores to lafficate specific equipmest,tae Tank ID: M 6 Tank ID: l YIn-Tank Gauging Probe, Model: V'/se WW` Tank Gauging Ptvbe. Model: Us Atmular Space or vault Sensor. Model: n7q r/34 O-4 ZU i3'Annular Space or vault Sensor. Model:Ablpo - q 2 WPiping Sump/Trench Sensot(s)• Model:_a 7,1q 3AO-2L8 Piping Sump/Trench Sensor(s). Model: C3Fill Sump Seamr(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Uf Electronic Line Leak Detector. Model 1 424-� SKElccdnnic Line Leak Detector. Model: Q-'Fank Overfill/High-Level Semsoc. Model: W &t 50 ®'Tank Overfill/High-Leve]Sensor. Model: 0 W &I SO -a2tffuipment type"model in Section E na Page 2). ❑ Otherequipment tYpe and model in Section E on Pa 2). Tank ID:— W 4-STr 62!L 1 Tank ID: ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: I4'Anaular space or vault sensor. Model: d 79 'Y,31 0-Y?0 13Ammiar Space or Vault Sensor. Model: lB`Pipiag Sunp/Trench Sensor(s). Modd: b 71 Y33 0-21.49 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sersa(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leah Detector. Model: ❑ Mechanical Lime Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leek Detector. Model: U r mk Overfill/High-Level Sensor. Model:--07 k 3 40-y2O ❑ Tank Overfill/High-Level Sensor. Maid: ❑ Other and meld in Section E on P 2). C3 Other eat and model in Section E on P 2 DI ID: kA/LO-R) /X7— Dispenser ID: NGcf)9-b er Containment Seasor(s).�. Model: 074�/,M-208 ispenser Containment Sensor(s). Model: 0 Zj!y 90--208 F Valve(s). 0 10rt) alhear Vaive(a). 47l4u/ ❑ DisPenser Containment s and Chain(s). ❑ ser Containment FI s and Chains. Disppenmser ID; - Z ;- Dispenser ID. WrDispemec Containment Sense s).! Model: 0 79 y3eoZ�-Zoq ❑ Dispenser Containment Sensor(s). Model: 'Sheer Valve[a. mow ❑ Shear Valve(s). ❑ Mons Cmtaittmeat FI sand Chain(s), ❑ Dispenser Containment Float(s) and Ch ' s. Dispenser ID: Dispenser ID: ❑ Dispenses Containment Sensor(s). Model: Cl Dispenser Containment Sensor(s). Model: ❑ Shear valve(s). ❑ Shear Valve(s). 113Dispenser Containment FI s and Chairs . ❑ Containment Fl sand s . 'If the 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 ideotifled in this document was inspectediserviced in accordance with the manufactmrers' galdelines. Attached to this Gerdfkadon Is Information (erg. manafacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring"meat. For any equipment capable of generating such reports,I have also attached a oopy of the re rt;(#heck oil ihat?pply): ystem set-up ff-, arm,.�tlstory report Technician Name(print):-7i}Ttic%� Signature: y Gfit/l�vt Certification No.: 14 2 0 2 License.No.: Testing Company Name:A&W&tt< 9, -56Xy dzz;UIlo 4rge Phone No-:( 7 6 Site Address: 4/0 Wo Weer Gt�77/�_ Date of Testing/Servicing: /Z/AD/ 0-7 Page 1 of 3 03/01 Monitoring System Certification