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JN For Use B".1/l.Inrisclictions Iffithin the.Shale ref Caliijbrvriu e (; 1 Anllrorily Owl: Chapler 6.7, Health and 'qfe y Cocke; Chapter 16, Dirision 3, Tille 23, Californici�U�e of Re 20/08rns This form must be used to document testing and servicing of monitoring equipment. A se�araJ IT HEA TH copy �f 01 must be prepared for each monitoring system control panel by the technician who performs the work. A co of i i a vicled 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 r Facility Name: I G (� r(^ j.�� Bldg.No.: Site Address: 1 Via City: I-od 1 Zi p:: 5�, Ll z Facility.Contact Person: �_t t / Contact Phone No.: (Z U'1 ) 3-3 y - OG 1 rj Make/Model of Monitoring System: Vf,Cdf-d ;Lt:>t?l, L 6 .5 -�,5{) Date of Testing/Servicing: a112 3 /( B. Inventory of Equipment Tested/Certified Check thea, rn riate boxes to indicates ecific equipment ins ectewserviced: Tank ID: OCA+ Tank 1D: In-Tank Gauging Probe. Model: ��9 4 In-Tank Gauging Probe. Model: LA A(, 1 CC Annular Space or Vault Sensor. Model: .ci Annular Space or Vault Sensor. Model: 'Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model:Fill Sump Sensor(s). Model: , lX Fill Sump Sensor(s). Model: [3'Mechanical Line Leak Detector. Model: Or 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 equipment ty a and model in Section E T Pa a 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). T:)nk ID: tAIV1 Tank ID: lav C� In-Tank Gauging Probe. Model: N1 V/A b 1 A In-Tank Gauging Probe. Model: 0 A Annular Space or Vault Sensor. Model: H Annular Space or Vault Sensor. Model: LY Piping Sump/Trench Sensor(s). Model ❑'Piping Sump/Trench Sensor(s). Model op, CYFtll Sump Sensor(s). Model: UFill Sump Sensor(s). Model: ❑(Mechanical Line Leak Detector. Model: ❑'Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ T&nk Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ' ❑ Other(s ecif e ui ment t e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Page 2). Dispenser ID: 3 Z Dispenser ID: ✓ f ❑Y Dispenser Containment Sensor(s). Model: 2 n ❑'Dispenser Containment Sensor(s). Model: > , 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis censer Containment Float(s)and Chain(s)• ❑ Dis enser Containment Floats)and Chain(s). Dispenser ID: E, 5 (� Dispenser ID: Ll'Dispenser Containment Sensor(s). Model: Z,C�9� ,d Dispenser Containment Sensor(s). Model: >' O Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 5 Dispenser 1D:_(� t 7 O/Dispenser Containment Sensor(s). Model: 2092 ❑"Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). "ll'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 equipment. For any equippient.capable of generating such reports,I have also attached a copy of the report;(check all that apphp): l2f s"st-u Alarm his ort Technician Name(print),,: 11Fee'lix Ramirez Signature:Certification No.:163`� AIG License.N .. O40 ICC#5273934-UT Testing Comp/an'y(Name: U2�1� ES - Phone No.:�2 tel �-ILI L� U t I Z Site Address:LL42 I �n�!�C,•�, Date of Testing/Servicing: UZ/Z 3/0A v - . Page 1 of 03/0I Monitoring System Certification D. Results of Testing/Servicing