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MON: ORING SYSTEM CERTIFi _ATION 'W J For Use Bv.4//Jurisdictions Willrin 1he Seale of California A ulhoriry Cited Clurpler 6.7, Heallh and.S'gfely Code; Chapter 16, Division 3, Tille 23, California Code of Regrdations 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 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 forth to the local agency regulating UST systems within 30 clays of test date A. General Information Facility Name: 4,er &sal A14412:7 Bldg.No.: Site Address: 40773- S. P��gS(�,J P �y: T G y Zip: !� �7 Facility Contact Person: /(J(��'L Contact Phone No.:(20 ) ".--7777 Make/Model of Monitoring System: TtT -ZSa Date of Testing/Seryicing: 3 / r / o S. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicates eciric equip ment in ecfed/serviced: FanD: Q��'— t p/� �'7 Tank ID: ank Gauging Probe. odel: 4244 / �In-Tank Gauging Probe. Model: ular Space or Vault Sensor. Model: `/07 2(Annular Space or Vault Sensor. Model:png Sump/Trench Sensor(s). Model: O OPiping Sump/Trench Sensor(s). Model:_ Zp Fill Sump Sensor(s). Model: ZU 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 2f Electronic Line Leak Detector. Model: G) ❑ 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(s eci equipment t e and model in Section E on Pae 2). Tank ID: � S)AV2 7 Tank ID: '4 I In-Tank Gauging Probe. Model: 1*14 t / A In-Tank Gauging Probe. Model: / nnular Space or Vault Sensor. Model: yb7AT Annular Space or Vault Sensor. Model: 0 7 Piping Sump/Trench Sensor(s). Model: J A Piping Sump/Trench Sensor(s). Model: Zp Fill Sump Sensor(s). Model: ZD U Fill Sump Sensor(s). Model: (3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: • ❑ Electronic Line-Leak Detector. Model: Wr 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 F on Paee 2). ❑ Other(s ecif)�e ui orient type and model in Section E on Page 2). Dispenser ID: ` Z-- Dispenser ID: t=4 I Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: t 7DF ,ef Shear Valve(s). EJ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Floats)and Chain(s). D• penser ID: — Dispenser ID:_ 2—.d Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Z � y7 Shear Valve(s). /Zl Shear)Valve(s). ❑ Dis eraser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). I: ❑ Dispenser Containment SeiiisorjW Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)2,d�Ch n(s). ❑ Dispenser Containment F,at )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 eq ment. F�anyequ' Hent capable of generating such reports,I have also attacw a copy of the r port;(check all that npp/p): S Ala istory report Technician Name(print): •.e.14K) /KD Signature:: Certification No.: License.No.: le Testing Company Name: rroaP/4 /F57 PhoneNo.:� 20 9 � Site Address: ZJ`71,1S, A77ECSdr✓ 'P155 Date of Testing/Servicing: 0_11 Page I of 03/01 Monitoring System Certification D. Results of Testing/Servicing S3 (-