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19255517888 Main Fax GETTLER RYAN INC '0:08 p.1n. 01-11-2007 5/11 MONITORING SYSTEM CERTIFICATION 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 ibis form must be used to document testing and servicing of monitoring equipment. A separate certification or rennet must be prepared for each monitoring system con�ol 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: A (RC � # �' � Bldg. No_: Site Addrzss: 3 Z / 2 N Ca % � � � �' City: _5�1pC4 d, C4 Zip: ----�^ Facility Contact Person: We�ud-, -S',, e c 4 Contact Phone No.: ( _) Make)Model of Monitoring System: Z 72-S 7)—o Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified (beak the appropriate boxes to indlieste spceifie egatpraeat faspeeted/servteeds Tank ID: `9 / Y "ae,* + e ❑ In -Tank Gauging Probe Model. ❑ Annular Space or Vault Sensor. Model: >QPiping Sump / Trench Sensor(s). Model: ❑ Fill Sump Smsor(s). Model: O Mechanical Line Leak Dowdor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ❑ In -Tank Ganging Probe. Model: ❑ Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Litre Leat Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -bevel Sensor. Model: ❑ Other (specify type and model in Section E on Page 2). Dispenser ID• 4 Al�DispenserContajmncntScnvo,r(s). Model: -:� 5 y3,fa - 3 Z.3 Shear Valve(s). Dispenser Containment Floet(s) sad Chain(s). Dispenser ID• ❑ Digx ma Coatainment Sensor(s). Model: O Shea Valve(s). ❑ Dispenser Containment Fload(s) and Chain(s). Dispenser ID: O Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). ❑Dispe:nser Containment Float(s) and Chain(s). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model- ❑ Piping Sump / Trench Sensor(s). Model: O Fill Sump Sensor(s)- Model: ❑ Mahaainl Linc Leak Detector. Model: O Eleca uric Line Leak Detector. Model - Ll Talc Overfill / High -Level Sensor. Model: O Otho (specify Notpmat h7k and model m Section Eon page 2). Task ID• ❑ In -Took Gauging Probe. Modd: O Annular Space or Vank Sensor. Model: O Piping Sump / Trench Sensor(s). Model: ❑ Fir Sump Sensor(:). Model: ❑ Medd Line Leak Detector. Model: O Elecmonic Line Leak Detector. Modd: ❑ Tack Overfill / Hiab4.evd Sensor. Model: ❑ Odic (specify equipmcat type and Madel m Section E on Page 2). Dispeasar ID: ❑ Dispenser Containment Smsor(s). Model: ❑ Shur Vatve(s). O Dispmw Cotrtainment Hosts) and Chain(s). Dispenser ID: O Dispeaxr Containment Seesor(s). Model: ❑ Shea Vah*s). O Dispenser Containment Float(s) and Chain(s). Dispenser ID: O Dispenser Conlaimucat Soasor(s). Model: ❑ Shear Valve(s). O Dispenser Containment Floar(s) and Chsirn(s). •tfthe facility contains more tanks or d Tenscm copy this form. Include information for every tank and dispenser at file 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 (ag. manufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment For any equip®ent capable of generating such reports, I have also attached a copy/ of a report; (chsc all that apply): *1tem set-up n Alsrpt history report 0n 11 (l O 4 Jcl cXic •� c _�L .r �e� Sigaarirre�s ,c ,yam // Technician Name (print): C Certification No.: 3 U/ 3 a' License. No.: Z 2 O S 3 Testing Company Name: L�%i Phone No.: 9 Z3. ) 5 / - })-SlJ� Site Address: Date of Testing/Servicing: / / `1 / O Page I of 3 03/01