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MOI'+tA RING SYSTEM CERTIFI ATION For Use By All Jurisdictions Within the State of California Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This font] most be uscd to dvluurcfrt testing turd servicing of monitoring equipment. I the faeilA separate certification or report must be prepared for each monitorine system control panel by the technician who performs the work. A copy of this form must be 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: GXco-k I ru, 7 (o Bldg. No.: SiteAddfoss: ao GwNi ,lrtc k8. City: / Zip: Facility Contact Person: CV, t � Contact Phone No.: Make/Model of Monitoring System: ('r,\ Ili � .�� ,� 1.=t'IC_ B. Inventory of Equipment Tested/Certified Date of T ' (3 NOIilAN3 = JuNnOO Nlnovor turfs 2� Check the Oppropriate boles to indicatespecific equipment ins ected/servicede: r Ta"k iii: B7 Tank ID: ❑ In -Tank Gauging Probe. Model: 9Annular Space or Vault Sensor, Model: "Piping ❑ In -Tank Gauging Probe. l: Annular Space or Vault (11r;r Sump / Trench Sensor(s). Model:_ c _It I ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ,01ft.cffianical Line Leak Detector. Model: }�1 L.�aO(1� (Mechanical Line Leak Detector. Model:, }/fl�Lfl71Db17 ❑ e,jectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ LI Tank Gvertill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: k � Tank ID: ❑ Ill Tank ^ `._, _'::I' Annular Space or Vault Sensor. Model: `— ❑ L.-.. a uuubaur, i'.�.lG. Model: C3 Annular Space or Vault Sensor. Model: J9 Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: a Fill Surup Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; iii.ri + LL) Xj1(� ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: []'Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: lv-a Dispenser ID: -�-Q ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment•Sensor(s). Model: Shear Valve(s). [aShear Valve(s). Dispac. Cvuiauai.oui Fiva:(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: r ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valvo(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model; [] Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) 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 Site -Plot Plan showing the layout of monitoring equipment. For any egyr went capable of generatin such reports, I have also attached a copy of the report; (check all that apply): System set-up [Alarm history reportvet�'�U Technician Name (print): Tony Fontana Signature: Certification No.: V.R. A23686 ICC 5289227 -UT License. No.: A- 84628 Testing Company Name: U.S.T. Compliance Testing Inc. Phone No.: (209) 595-4489 Testing Company Address: P.O. Box 580 Ceres, CA 95307 Date of Testing/Servicing: -13 UN -036 —1/6 www.unidocs.org Rev. 01/17/08