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OV-28-2006 09:36 ice Station Systems 408 938 8888 P.02 Authors Cued' Por u4d dy AuA►Irdictiont within the Stott�f Caltfnrnta rJ' Chapter 6,7.H#""A rind Safety Code;Chapter 16,Dtvjt'ian 5, rt1R 23, Caltfa»tfa Code of a lotion y This form must be lysed to document ttsting and servicing of monitoring equipment. se Ceti or ntr ' by the�chrlicie.n who pet2rms the work, A copy of this farm must be provided to the tank syatem tc nst d optrater. The owner/operator must submit a copy of this forme to the local agency regulating LIST sytn� within 30 day6 of lost date. A. General Iuforua •fit? Facility Name: I Site Address: 110 _ 4Jdg.No,:�� Facility Ceniaci Person; 'Stt41*- city: Zip:._ e./M Makodel of Monitoring System: Contact Phorte No,: a( L 1- 59 2 - $. Inventory of�,, p `------ - Date of Testing/Servlcing: _10 chick the,1roiHatebo�ULrma.ltT'�ted/C�rtifiedd4 ked: Tank LD. .i R In-Tank Gauging Probc, Tank ID:Z V l f-5ikt- U Annular Space or Vault Setraor, Mcdcl: — 0 la-Tsak Oaai ng Fmhe. Model: ❑ piping Sump/Trone}r Sellaor(t). Model,' G Annular Space or Vault Sensor, Model;_. ❑Fill Sump SMSW(3). ❑ Piping Sump/Tretteh Sensor($), Modot; ModoL ❑Fill Sump Seasor(s)• Modal; Mechanical Lie Leak Dmotor. ModeE GD p Llecrroaic Line Leak Detector, Model: Mechanical Line Leak betectvr, Madel: �) Tank Ovafril/Higb-Laud)segtor. Model' G Eteotronie Lino Leak Dctocwr, Model: G Other(specify cqui22ent and model in Scctian Eon page 2. ��r(spccifl/&ph nte!Sensnd model in 5ecdon ion Pae , Tank ID: 0 En-Tank f3augiag Probe, Model: Tauk ID; ❑ Annular Space or Vault Sowe, AModal. ❑In-Tank Gauging Probe. Model: ❑ Piping Sump/Trench Senaor(s). Model:— G Aturilu Spacc or Vault Sensor. Model' l D Fill Sump Sonaor(a). Mode, 4 Piping Sump/Trcnch Semor(a). Model: 0 Fill Su ical Lina Lank Detector. C3 Fill Sump Smmr(a). Model: _ ❑Mechani LI rEleovonia Line Leak Detcaor. Model; —— cal Liao Leak Detector- Model: Q Tank OverCll/Mgb-isvcl Sensor. Model; ❑Electranic Lino beak Detector, Modch Othet' (specify ui men!type andmodel in Section E ott PR r a 0, TOtther specify pell/ u ha13�tand=del in Sectio I E on Pa 2), Dislienstr E1 D4 pa .user Dispenser Cantaiamero Sensor(s), Model: p user ID; A Shear Volvc(Sj, d Disyenanr Coetainment Sensor(sj. Mode}; ❑Di Baser Containment stops($ end Chains, d Shear Valve($), Dispenser ID: ❑ Dispenser Containma,t Floa a bad Cttatn s ❑ Dispenser Contaianeot Se s, Dispenser D7: D Shear Valve(s). ) Madel: Dispenser Containment Soneor(s), Modcl: LUDispinsgr rrear Contalnmeat play s and Chain a. ❑Shor Valve($), Q Die aser Cotttaiament Floats and Cha' s r TD: Dispenser M: naw Containment 6attaor(s). Model; R Ditpcuacr Coot nr;na�nt$fit Velve(a). ❑ Shear Valvo(s), aar(s). Model: Containment Fl..,(,) loe s and Chains. ❑ Di user Cantaittmtinr Fioat(e)and Chains_ `If rite fitcility contains more tanks or dispensers.*cPY rhes form. Include iuformuion fat tvery tank and dispenser at the facility. C. Certification - I certify that the eci4meot Identified In this documutt was inspected/serviced In accordance with the Infer Aatioren'gutdeliaes Attached to tdl,Cer1111cadon is Information(e,g-manufacturers'checklista)novessary to verify that chip Information 1s carrect and a plot Plan showing the Iayout of monitoring equipment. For any equlpmeat aapable of generating such reports,I have tiro aturbed a gopy of the reporti(check all that apply): O S se up 0 Alarm history report Techniriaa Nwme(print): ..l . pf� j Signature: Certification No.._ License.No.. Testing Company Name., Phone ��- �. Site Addrosa' 1S Date of Teatin g/Servicing: Monitoring System Certtlleation Pa$e 1 of u�ut D. Results of Testing/Servicing