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' .' _. ..._•� ... va..�atuarn ti.laal�lll�Hiltllr For Use By All Juriatlictlons Within the State ofCali orgta QR)AFT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16.Din�lier ( � 3�Calitnrpiy;Cude of Regie atiuns NTMIT SFRVICE This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a seyiUJAN ftaftl&jWrt must be Dteoared'for each monitoring system control panel by the technician who performs the work. A copy of this form mush be provided to the tank system owner/operator. The owner/operator roust submit a copy of this fort to the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. A. GeneralInformation Facility Name: ! / M:.;rl t Ai / n Bldg.No.; Site Address: J 7 5 f V t�SOrI �&Y City: .s�ek70✓1 Zip Z 5 205 ,.I t Facility Contact Person: rje L0.` Contact Phone Pio.; T Make/Model of Monitoring System: Date of Testing/Servicing: l :2 tl/C.Z B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank n): c Tank ID: f "n-Tank Gouging Probe. Model: In-Took Gauging Probe. Madel• pT'Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: iping Stamp I Trench Sensor(s). ModcL Piping Sump/Trcnch Sensoi(s). Model: U Fiji Sump Sensor("). Model: U Fill Sump Sensor(s). Model: XMechanitel Line Leak Detector. Model: X Mechanical Line Leek Detector. Model: Q Electronic Line Lcuk Detector. Model. Q Elahonic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Level Sensor. Model: Q Dispenser Containment Senor("). Model: Q Dispenser Containment Scnsods). Model: Shear Valve(s). Shear Vafve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Q Other cify equipment t e and model In Section E on Pagc 2). Q Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In•Tudr Gauging Probe. Model: Q In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor, Model: Q Piping Sump/Trench Sensor(s). Model: Q Piping Sump/Trench Sensor(s). Modcl: _ Q Fill Sump Sensor(s). Model: Q Fill Sump Stru or(s). Model: • Mechanical Line Leak Detector. Model: Q Mechanics]Line Leak Detector. Modcl: ❑ Electronic Linc Leak Detector. Model: Q Electronic Linc Leak Detector. Madel: Q Tank Overnll f High-Level Sensor. Model Q Tank Overfill t High-Leve(Sensor. Model: Q.Dispcnsor Containment Scnsor(s), Model: ❑ Dispenser Containment Scnsor(s). Model: Q Sheer Valve(s). Q Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)and Chain(s). Cl Other(specify equiptracrut type and model in Section E on Page 2). Q Other(specify equipment type and model in Section E on Pae 2). C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with tfie manufacturers' guidelines. Attached to this Certification it information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,t have also attached a copy of the(check all that apply): ❑System set-up report-, ❑Alarm history report. 1 I i TechnicianNami�e(print): t(;liM Lee—dfutLio-.c�Cert./Lie.No.: o .i ja Signature:� /L_ �y ` M((7 1` r 9 7 Testing Company Name:��C�e JJ � s, l Q,..Linc:hie— _&� Phone No.:( f0 0 � CALM-01 Page I of 3 1 tit 5799