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MOP ,ORING SYSTEM CERTI. CATION For Use By All Jurisdictions Within the Slate of California Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 2.3, California Code of Regulations This form mush be used to document testing and servicing of monitoring equipment. A eedarat. rPrtification or anon must b f(�r tach monitoring System control anel by the technician who perforrns.tlie work. A copy of this form must be provide, to the tank syst�m owner/operator. The owner/operator must submit a copy of this form to.the local agency regulating UST system. within 30 days of test date. A. Gencrali�Information Facility Name: �- R 1''l t ln', j"1 a✓ �- `7 L7 Bldg.,No.: Site Address: Zs 7'7 5 Soot 4-h �� '�-� z rson P4 ss a-� city: `ru c zi 5 3-7 L P' Facility Contact Person: G i r 4 1��4 e � Contact Phone No.: ( �of ) 03s— 777`7 Make/Model of Monitoring System: U�e`e r- iZo4)4-TL 5 35 d Date of Testing/Servicing: 3/ I 1 C�� B. Inventory of Equipment Tested/Certified Check thea ride boxes to indicale s ecine a ul menf ins ecled/serviced: FID � 3lv_a SrD� vr1 a-V1, Tank ID: #�Z 3Ltti� Gauging Probe, Model: 5 rL -�( U (a ✓ 8 �_ � VYl G q K1n=Tank Gauging Probe. Model: yy) G V 2 cIt.v- �T,o 4-- Space or Vault Sensor. Model: '� t/ q_tJj �nuarS�acc or Vau)l Sensor. Model: �t U-1 a J �,U Y `U7 ` `�ump/Trench Senxv(x) Model:07`(L13�0-2-vFsi/ P4Ping$ump 1 Trench Sensor(s). Model:01�y3E-o-2Sensors U��A-0p ( )• Model:Z77`tU3gb-Lvg umpSer�sor(s). Model:a�4•�(3kD-2✓-IZ-u �- _cal Line Leak Detector. Model: O Mechanical Line Leak Detector• Modol: ❑ Electrunic Line Leak Dcicctor. Model: Electronic Linc Lcak Detector. Model: �Tean`k OYe411/High-Level Sensor. Model:� k eco, ll/ LLD V2��✓ AZ; rJ. Tank Overfill /Hu�ggh-Level Sensor. Mudl l: .J V-QP- �--yz-&C� t 4 � CI Other(s cif c ui menf l e and model in Section E on Paa 2). ❑ Other(s if c Tank ID: ui menf type and model in Section E'un Pace 2), -t 3 1tn t 5 ��v� Qk Lam✓ Kin-Tank Gauging Probe, Tank iD: � { Model: k� n-Tank Gauging Probc- Vee�V-� Model: A�rr��wiulaF Space or Viault Sensor. Model: 7,(1f 3 V ✓-�av�` ✓ v'8ko ✓_r�� 9-ui 01 ,Annular Space or Vault Sensor, Mode 1:7-q P�ippting Sump/Trench Sensor(s). Model: y $t�_ V r /r y U7 V-p;�Q.✓- tZo-�T 3 g 'Piping Sump/'[tench Sensor(s). Modc1:0-71L4 3Fr0-2.!$ 17 Su�!�tp goo S)• Model: 0-It 3SU=Zo$ \ V coir--r2-ve. I— r F ) Sumpens Model: d"l �iL4 39d-2-ot; O MechariicalLine Leak Detector. Model! ❑ Mechanical Line Leak Detector. Model: O Electronic Line Lcak Detector. Model: _ Electronic Linc_Leak Director. Model: P T?r4k Ovfrfill/High•Lcvel Sensor, Madel: u �- V e Q 'c e✓�-Ej U 4— Y►'trc q Z full I Ov till/ t ligh•L4 vcl Scusor. ❑ 011ier(s ecif ui ment tv and model In Section I;on Pn a 2). ❑ p`}1G f e u mcnl t e and mock Model: V►�L�S Dispenser ID: �= t l in Section L: on.Pu a 2). ❑ ��ispuu4r Containment Scnsor(s), Mode); Dispenser ID: 1 3 r L- -P- Y_ 7cl,q{ '2ry~Zvi. C7 Dispenser Containment Sensor(s), Model: O Shear valve(s). V e-e-C e✓- tZoar v O D' ser Containmciit Flout(s) and Chain(s). ❑ shear Valvc(s), -7 `i 3SSv- ZO r O Dis nser Cuntainnicnt Float s) and Chain(s). Disperser ID:11-Cf le O D' Dispenser ID: Dispenser Containment Scnsor(s). Model• ❑ Dpis � F-g ____ --eA¢-v'- 1_ cx - � penser Containment Sensor(s). Model ❑ Shear Valve(s). U�ert.�✓-l'Lvo�- ❑ Di user;Containment Floats and.Chains . 0 Shear Valve(s) a 7 q1-(3&U -'._•08'. D'FsPe:as.t:_ilj: ❑ Dis nser Containment Floats) and Chain(s). ❑ Dispenscr.Conlamm Senso.$) M0 C nser iDt ❑ Dispenser rnrlain Scusor s),-.aM.o,de.l; dT)r nser Contalnmcat Fioat(s) and Chain (s). Shear Valva(s). ❑'25'is ate-" - *If the facility contains more tanks or dispensers, copy this form, include c-,, Containment Float(s and Chain sp Information for ev try tank and dispenser ut Clic facility.