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02-09-'06 10:41 FROM-W jig 7076932922 � T-221 P002/005 F-224 <br /> e <br /> Rip <br /> r Gal.Code Regs.Me 23,Division 3,Chapter 16,Underground Tank Regulations <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By AliJudedlctfons yYdhin the State of Callfomia <br /> Auurofny Caed:Chapter 6.7,Heef r and Safety Coda;Chapter 78,Vivierva.7 74re 2.3 ColJomia Code of Regulation <br /> This tomo must be used to document teafmi;and servicing of monitoring equipment A separate cawfloo n ar Fennot mus Lm <br /> gtslpqSadL each m njip ino sys[sm conkvl pedal 6Y reel tecimician who performs the work. A copy of this form mus[Fac provided <br /> to the tank system ownerfoperamr. The ownedoperator must submit a copy of Ifs form to the local agency regulating UST systems <br /> within 30 days of test date. <br /> A. 43weral Infounmation <br /> FacaftyNam : r � <br /> Bldg• <br /> site Address: '-�O AO W&-S7- <br /> �^ t <br /> Facility Gbntacl Person: 4TA� contact Phone No.: <br /> MakefModel W Monifoarg System:�( I� !?48^ S 3�� ❑are OfTesitng/Se d V V <br /> B. tnventoryof Equipment TastaNCeMed <br /> Chock ba brpres to ipdiaT� i menti sarviwd: <br /> Tank IlkC9 d'7 Tank ilk <br /> In•Ter* ging Probe. Moder: <br /> AnmlarSpaCe W Vault Setlsor. Mo Annular Space W Vault Sang. Model: <br /> Plift Sump/Tn:rrdr9ensa(s). Model:, - JF Piping Sump/Ytehch seasons)- Moret: <br /> Fill S mp Sansor(s). Model: ❑ FW Sump Sensuft Model: <br /> ❑ Medien(cal[erne LeaK De MF. Modek 0 Mechanical Line leek Defector. Madel: <br /> jt( F_fectronic tine tEaK❑al8dor. Modm: Eleckomc Una Leak Detector. Model o+' <br /> ❑ Tank Owxflfl/Oitgh-Level Sansoc Modar -C) Tank 0vwfi0/Htg�L Wl Senear. model: <br /> q 0011'e, and model in Section E w a ❑ Other and modal kr 1 , E on!age 2), <br /> Tank ID: f Tank10- <br /> LT m Tank Gauging Probe. Modal: (3 in-Tan[c Gauging Rube. Modet <br /> 9 Annular Spaceorvault Sensor. Modal:, +� ❑ Amulet SpaceW Valdtserrsot. Medet <br /> 10 Piphtg.sump lTrcnch Sm>mr(s)- Madel - ❑ Piping Sump/TM6.ch Sensa(s). Madel: <br /> ❑ FlOSump Sensors) Model: 0 FaIauznVSarrsor(s)- Mod8t _•,_ <br /> ❑ Medurkal Lira Leek Detector. Model: ❑ MBc7tmdCal Line iPak Detstlor. Medot <br /> ❑ Electronic Line 1Sak Detector Model: 17 ❑ Electronic Lina Ledk DeteCiW. Mach' <br /> jr TeabfireflNd Htgh-Laval$cosec Model: O Tank OVEMI Higrrlievel eensor. Model:— <br /> ❑ gprar s ane modal m S¢enNr E as A0Omar - and model in 3ec4w E an z. <br /> DispwmarlD: "' ns"Ilk r •_ <br /> Dkpepsor contairmrent senscr(s). Model:,-,�j. .. - t7cponSar4brrmirmwM�rgm(s)- ModeE Z <br /> I shearvah")- ShearValve(s). <br /> ❑ Co f z and Ctiainti). - q MEMOortairtmem s and Chain <br /> Wspeorsorro: f ^ 0lspenstrlD: .. <br /> ,1f D➢spenserCmtafnn�ent Seraar(s)- Modal: .EtB ❑ 0tsperser CmrrtatrlmenH sensw(s)- Mcdaf:_ <br /> -Rhearvalve(s). D ShearVaMe(s). <br /> q Corrta7mnent s and CFrel s. ❑ D1aAanserCaidain'merrH F'baf(s)and <br /> 0fstxnseri0: vlwwresrl0: ' <br /> O OispBlrSBr ComaNmantSetuor(s). Model: Madel:_ <br /> ❑ Sltaazv9tvo(s). ❑ shearvaNats)- . <br /> q L CantatnmaM 8 and Chakrs O 0bpeaearContainmeni and Chains. <br /> 'If 6refadl�wntalns arena tonere ordlatamaers.oopY t#lis Porn. include infortmadon fWaverytahkarid dispenseratfhefBc1*- <br /> C. CaNncatlen-I ceNlfy thatthe equipment identified In this documontwas IMpectadlSarKCCd In a60andaAw with the <br /> rnanrdacarrors'guWaOnas. Attached to this Certtgcadon Is hdonnatbn(e.g.manufacturarr'ahecklists)eocassarytc verify that <br /> err hd6rejagan is eonoetanda Prot plan showing the layout of monttoring aquilmtent Fwargrequl ntcepabtoofgenoradng <br /> such repoi%I haw alaoattached a.up/y�ofthe report;tcheckall Mai a'): ❑System/soWlt QNamt history relrod <br /> Technldan Name(print):/M 1Lr Fi/4eL A6&t.P,3 Signature: ¢ — <br /> CerMcaum Na: ZZ N3 rJ Licenser.No.: 9-5'9'17T Z- <br /> TesdngCompanYNarne: .CC.+=/'E 7' r�tco PhorleNo.:tiS'3 7SS-IVZf <br /> sdeada,asa: S�OS�l� LtJ � DateofTestlr�lsatvidn�-.[-/_;�J��.._... <br /> 107- <br />