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I , ' MONITuRING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited-Chapter 6.7, Health and Safety Code; Chapter T,5, Division 3, Title 23, California Code of Regulations "iis form must he used to document testing and servicing of monitoring equipmt.nt- ,e.�;}�y;..�p�r a "station or re}�o, r�a��tst be oreoarod for ems:'-ng�.�`dgtn�ptrol n by the technician who performs the wort:,. A copy of this form must be provided to the tank system owner/ope.ator. The must submit a copy 4f tk!LIEr t ►ma y_i regulating UST sysmias within 30 days of test date. `¢ ' JUN 0 7 2016 A. Genend Information • r'*�rK. �►�- Facility Name: C'itvl4'rw �l 'Site Address: — ---• Facility Contact Person: Contact Phone No.: Make/Model iodel of Monitoring System: j- . Date of Testing/Servicing: B. Inventory of Equipment TesteWCertified f Check the 6propriste boxes to indicate s IIc equipment Inspected/se,vicetFt: Tank ID: Tank ID: ❑in-Tank Gauging Probe. _Model: _ 1,t-Tank Gauging Probe. Model: )(Annular Sparc or Vault Sensor. Modes:"'° _____ A.nrtular Space or Vault Sensor. Model: Piping 5urrsp/Trench Sensor(s). _ Esping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: _ bili Sump Sensor(:). Modes: MF �mobanieal Line Leak Detector. Model: 11}�[�,© � Xld�i�Line�Detector. Model: ❑glectronic Line Leak Detector. Model: _ ❑1:1ectronic Line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: Aw a*overfill/High-Level Sensor. Model: Other(specify eq►tVaient type and model in Section on Page 2). )ever(specify equipment type and model in Section Page 2). Tank 11D: —L Tank ID: ❑In-Tanis Gauging Probe. Model: _ _ ❑ n-Tank Gauging Probe. Model: 49 Annular Space or Vault Sensor. Model: ❑ knnular Space or Vault Sensor. Model: 1%Piping Sump/Trench Sensor(s). Model:-- _ [3 'iping Sump I Trench Sensor(s). Model: Fill Sump Sensor(s). Model:5 ❑ 7-ill Sump Sensor(s). Model: Modmicai Line Leak Detector. Model: ❑ viechanical Line Leak Detector, Model: Electronic Line Leak Detector. Model: _ ❑ lectroaic Line Leak Detector. Model: a Tank Overfill/High-i evel Sensor. siodeltim ❑ Tank Overfill/High-Level Sensor. Model: ❑Ocher(specify equipment type acid model in Sectiolft on Page 2). [3- (specify equipment type and model in Section E on Page 2). Dispenser ID: )"" 9 Dispenser M. Dispenser Containment Sensor(:). Modcl: "" 7. Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑Dispenser Conuunmcnt Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chtin(s). DispenserID: i D* penser ID: +� Dispeam Gomai»eat Smsor(s). Model: - 52Z Dispenser Containment Sensor(s). Model: .�- Shear Valve(s). ❑shear Valve(s). ❑Dispcn=Containment Floats)and Chnin(s)- ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: " L Dispenser ID: -"� • DispenserContainment Sensor(s). Model:-.-WS r. RIDispense'Comainment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Disperser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include infommuon for every tank and dispenser at the facility. C. CertlfiCatlon-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. manufachnWs' checklists) necessary to verify that this information is correct and a Site-Piot Plan showing the layout of monitor ing wpa-ent. For any eqgipment capable of geeeratir tech rqWr I have also attached a copy of the report;(clrack aU that q ply): Sy item set-up Ala to -�, ,�. WA Technician Flame(pr:itt): Tony Fontana S guawre: Certification No.: V.R.A23888 ICC 52882274UT L:sense.No.: A-848 Testing Company Mame: U.S.T.Couppaime Testing Inc. Phone No.:(249) 596.4489 Testing Company Address: P.O.Box WO Coms,CA 95307 Date of Tesd*Servicing: •" ups-ou-rib -uasdac--nom