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MONI"'ORIN6 SYSTEM C'ERTIFT kTJON I _Ise B),AH Jrn•isdictions Il7thin the Stca/e of Calijo, ,it, .4whor-ity Cited: Chapter- 6.7, Health and Sgfety Code; Chapter /6, Division 3, Title 23, California Cade of'Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician 1=4 copy of this form must be provided to the tank system owner/operator. The owner/operator must submit 1� ocal agency regulating UST systems within 30 days oii ct date. I A. General Infos Dation Facility Name: pLTL UNI 0 6 2008 Site Address: _�O 1 6. (f/tlo?-'e ENVI6� Facility Contact Person:-!;PA(hd ER Pal Bldg. No.: Zip: No.: (ZC> 7 ) G/G a- 03o S Make/Model of Monitoring System: 7' ^J c p.\j %S - /nno Date of Testing/Servicing: _T_/Z'//02 B. Inventory of Equipment Tested/Certified GFS Cheer: the appropriate boxes to indicate specific a ni ment ins ected/seni uc • I Dispenser ID: Dispenser 1D: ❑ Dispenser Containment Sensor(s). oriel: ❑Dispenser Containment Sen s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and iain(s). ❑ Dispenser Containment F oat ) and Chain(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 identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equi lent. For any equip ent capable of generating such reports, I have also attached a copy of the report; (check u!/shat app/Y): System set-up Alarm history report Technician Name (print): ,' Vi IZ( ��n klP Signatur : l Certification No.: License. No.: Testing Company Name: 'nr bA r P57- Phone No.:(,gVq� %~/�. 611Z Site Address: 70/ CA,e- r - Ge Date of Testing/Servicing: S17-1108 Page I of 3 Monitoring System Certification CI. Re-'i1Glts o G�:;t6eGLry��y G't GEGGa� 03/01 . Tank ID: ncA- Ta kID: I n -Tank Gauging Probe. Model: _(� In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Fi _ Piping Sump /Trench Sensor(s). Model: ULS anular Space or Vault Sensor. Model: Piping Sump, ump /Trench Sensor(s). Model: L Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 'jP —_44 CV ❑ Fill Sump Sensor(s). Mechanical _ Model: Line Leak Detector. Model:a .-I V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment type and model in Section E on Page 2). ❑ Other (s ecif a uipment type and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: d2). ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify equi ment type and model in Section Eon Page ❑ Other (specify e ui ment type and model in Section E on Page 2). 7 D' penser ID: ) Containment Sensor(s). D' ser ID: "� — Zispenser y vispenser Model: oz S �ear Valve(s).X Containment Sensor(s). Model: Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). sp ID: ,~ (; Denser ID:Dispenser Containment Sensor(s). Model: L'6`� � ispenser Containment Sensor(s). Model: Shear Valve(s). Lj[JV Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s)• Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser 1D: ❑ Dispenser Containment Sensor(s). oriel: ❑Dispenser Containment Sen s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and iain(s). ❑ Dispenser Containment F oat ) and Chain(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 identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equi lent. For any equip ent capable of generating such reports, I have also attached a copy of the report; (check u!/shat app/Y): System set-up Alarm history report Technician Name (print): ,' Vi IZ( ��n klP Signatur : l Certification No.: License. No.: Testing Company Name: 'nr bA r P57- Phone No.:(,gVq� %~/�. 611Z Site Address: 70/ CA,e- r - Ge Date of Testing/Servicing: S17-1108 Page I of 3 Monitoring System Certification CI. Re-'i1Glts o G�:;t6eGLry��y G't GEGGa� 03/01