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((�-11 E �i % F! I F:-: I U JUL 2 t 2 IOJ Fur Use BY .-(!! Jurisdictions Within the .SYule of Califbr•nia ,1 �rrlhorrly Cited Chapter 6.7, Heallh crud Safely Code; Chapter 16, Division 3, Tille 23, California Code r)~l e lnTr 06 ENV%t� llTH used to document testing and servicing of monitoring equipment. A separate certifE"QHV� gnitorine system control panel by the technician who performs the work. A copy of this fop tit t7lii; rtC '(o the tank system owner/operator. The-owner/operator mu - submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: FIGG &4 C .he r ot-s Bldg. No.: Site Address: �� ('r,,,�} c pyF Ci C , h'� L C>l� t Zip: 1 rj�,.-{2. Facility Contact Person: _ KOEW 1 b h i O , Soy Contact Phone No.: Q) 32A - nq'15 Make/Model of Monitoring System: cie'i R -f Y C) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sn erifir enuinnient insnrrh•d/crrvirnd• : ci l ccs Tank ID: �i�F =jam. ❑ In -Tank Gauging Probe. Model: nk Gauging Probe. Model: M ! �_ lar Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: Sump / Trench Sensor(s). Model: 9, OR Piping Sump / Trench Sensor(s). Model: Uump Sensor(s). Model: 90b FLine > Fill Sump Sensor(s). Model: anical Line Leak Detector. Model: --SVP M Ll� _ 2 -@f Mechanical Line Leak Detector. Model: LD 2000) onic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: (s ecify e ui tment ty a and model in Section E on Page 2). ❑ Other (specify equipment ty pe and model in Section E on PaLe 2). Tank ID: ('=i 7 (V) 1-11n Tank ID: sly In -Tank Gauging Probe. Model: M A (� 1 ❑ 1n -Tank Gauging Probe. Model: Uf Annular Space or Vault Sensor. Model: q Annular Space or Vault Sensor. Model: lJ Piping Sump / Trench Sensor(s). Model 1 _ rr EJ Fill Sump Sensor(s). Model: Gf Piping Sump / Trench Sensor(s). Model: SFill OP) 'EJ Mechanical Line Leak Detector. Model: 5TH M! Sump Sensor(s). Model: 12f Mechanical Line Leak Detector. Model: MI- ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e ui orient type and model in Section E on Page 2). ❑ Other (sped equipment ty a and model in Section E on Page 2). Dispenser ID: 1 3 2 Dispenser Dispenser Containment Sensor(s). Model: 2-05 4 Dispenser Containment Sensor(s). Model: p�� 0 Shear Valve(s). ®' Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Floats) and Chain(s). Dispenser ID: cf Dispenser ID: Q Ef` Dispenser Containment Sensor(s). Model: a og If Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). '¢f Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 6 " Dispenscr 1D: I I ' 12 Z Dispenser Containment Sensor(s). Model: O _ ,Uf Dispenser Containment Sensor(s). Model: 2. li Shear Valve(s). �13f+ Wr; Shear Valve(s). []Dispenser Containment Float(s) and Chain(s). I ❑ Dispenser Containment Float(s) and Chain(s). II the tacildy contains more tanks or dispensers, copy this tone. 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 equipment capable of generating such reports, I have also attached a copy of � the report; (check all that apply): Syst t — rm histol* Technician Name (print):—�1N€—LV—�mC� Signature: e� 533 7 u r Certification No.: License. No.: fIT--i ,, ^4 _ r. -."7., - Testing Company Name: -f- Phone No.: Site Address: HgCA U tv rot,3Date of Testing/Servicing: ()I /j�j Q Page I of 3 Monitoring System Certification A Results of Testing/Servicing 03/01