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MD J ll EC�f.l VED MONITORING SYSTEM CERTIFICATION SEP 2 6 2003 For Use By All Jurisdictions Within the State of Calij6rnia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter.16, Division 3, Title 23, California Code,6ljQ�� HFALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or retort must e�re>Skt�ciS for each monitoring system control Doane] by the technician who performs the work. A copy of this form must he 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: Bldg. No.: Site Address: "3 7(' yon � t? City: �(.4iy7'ECr9 . QA-. Zip: `tij 33� Facility Contact Person: Contact Phone No.: O Make/Model of Monitoring System:_U�- 12,--z5F 7`�5- -3,3c Date of Testing/Servicing: / -9 / 0`3 B. Inventory of Equipment Tested/Certified Cheek the a ro nate boxes to indicate=fie meat inspected/serviced: Tank ID: ! - -Prey" 4j� Tank ID: mT-ln_Tank Clanging Probe. Model: tit,- '/ ®'r-Tank Gauging Probe. Model: -I ular Space or Vault Sensor. Model: '7 SSr3 110-DO 1 Ia�nular Space or Vault Sensor. Model: 2-Piping Sump/Trench Sensor(s). Model 1 F"tc� Gi-T11Sump/Trench Sensor(s). Model: '--Y El Fill Sump Sensor(s). Model: ❑ fill Sump Sensor(s). Model: ®'Ciechanical Line Leak Detector. Model: // 27717�echanical Line Leak Detector. :Model: t 14. S� ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill f High-Level Sensor. Model: Other(s ifv equipment and model in Section E on P2je 2). ❑ Other(Sp2Ea equipment tv and model in Section E on Pa e 2). Tart ID: Z - Rte-uc,/��- `7 Tank ID: In-Tank Gauging Probe. Model: amu, -( ❑ In-Tank Gauging Probe. Model: nttlar Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 1 Sump Sensor(s). Model• ❑ 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(specify ui Tent _and model in Section E on Page 2). ❑ Other(specify equipment t)Te and model in Section E on Pae 2). Dispenser ID- 2 Dispenser ID: "7 I ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). L9 Dis user Containment Float(s)and Cham(s). ❑ Dis nser Containment Float(s)and Chain(s). Dispenser ID: "3-fK Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Fioat(s)and Chain(s). ❑ Dis n. Containment Floats)and Chain(s). Dispenser ID; 5-C Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis user Containment Fioat(s)and Chain(s). I ❑ Dispenser Containment Float(s)and Chain(s). *tf the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. Certification-1 certify that the equipment identified in this document was inspeetediseraiced in acevrdanee with the manuGrtturers' guidetines. .attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this infor-mation is correct and a Plot Plan showing the layout of monitoring equipitent. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): system set-up 2-X!h-Mn history report Technician Name(print): AL v,....i L, eco 1L&4t-.td Signature: �Jf✓' `"-�J Certification No.: License.No.: Testing Company Name: C��C��G[ t>i b/L% {�L�4; CIS�� fi;}a rC '� ir�5phone No.:( Site Address: -3 F y�x��t?`� (rfi��Cci C ( Date of Testing/Servicing:.-2-Ia_I Page 1 of 3 03101 Monitoring System Certification