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MONITOWNG SYSTEM CERTIFICATION MAR 14 2016 For Use By All JUrkd'Ct'o+ss WWI tjx State of Calrfor"'a Authurlty Cited:-Cftapter 6.7,Health and Safety Coa'e, Ch ter 16;Division 3, 71i1e? , ea1tfornirz N IN IAL rstt the work. This form must be til to document testing and servicing of taanitQr� g F L 4 cpm controi.pi by the teddlician Who p�s�s �A ifi n c of this forrtl to the!oral agalcY A copy of tl 5 form must ae provided to the tank systeu�o �er/operatos. TIM�zwnrs/aperatar mast submit a copy rcgutadr4 UST sysWrns within 30 days of test daze.-La�r3' A. Genand Information Bldg,No.: Facility Nauhe: Site Address: City: Contact Phone No.: t ,_ FaciJ.ity Contact PMOW -_�— --- ,� .. I)Ate of T tingf Servieiog Make nciel of lvtaaibori a Systcax: B. inventory of Equipment Test0WCert�ed Check kht,jAwro Ate tmesto indicate 5M eavinent ins u*servimit. Tank ID: Tank 10- C3 in-Tank cifflos probe. Madel; ❑In-Tank Gauging Frohe. Mocks: Annular Space or Vault Sensor. MO&L Annular Space or Vault Sensor, Model: Piping Sump 1 Tremdi Sensar(s). Mo&L Piping Sump/Trench Seftmrf s)� Model: -- Fill Sump 5catnor(a): Madel: — rill Sump SsraoT(s). Madel: '7- N*;jhaniea!kine Leak Odle or. Model; � Mcchan"Line Leah DeWctor• mom: joeowrk Linc Lcak Detector. Model: � ❑E.:ccamc.Line Lcak Detector. Moddi; Tmk-overfill/ -Levci Sensor. Madel: C�{'Fa+nk � overiil}r Fiigh-#..avcl +osot. Model, Z�, �T � ©Ocher(specify agvtcu nt type and modal in Sxn [Page 2). ❑Other(specifv equityPc and modal in Stcti au Page )• Task TD: Tank ID: Tn-Tank t wsmg Probe. Model: o lr.-Tank oauging probe. Modal: Annular Space or Vault Senear. Mom: — r 0 Annular Space ar Vault sensor, Modal; -- Piping Sump!Tremt Sensor(s), ©Piping bump I Trench seaaar(a). Made!' _ kill Sump Senspr(s). Model: .. Q Fill Sump Scnsor(a)- Model-, Meohaximd Line Leak L7ataciar. Model; ❑Mechanical Liao Usk Detector. Modei: lj FLcmonic Linc Lcak noaxtor. Mcxtcl: [3 Elects*-c bine Leak Detector, Madel: to Tank overf a!Hipp-1.cvot searsor, !clack!: Q C Teak overfill!High4xvcl Sensor. Modd: iI other(specif}equipatent typo and model in. Page Z), offset(specify equipment Mm$ad modal in Section E on PqF 2). Dispemer ED; Dupenw M, 10 Dispm=Constaiunmt Seas,(s). Model: .a Diapeoser Coow=ent Sensaa(9). Model: 0 sheen valve("). ©4FIeW Vatwe(s). Q Dispenser Contabm=t Flsaat(s)and Cl}n(s)- ©f;ispCer Coatfaits 4cw Float(s)and(`hdin(s). Dispenser int L �P Disptlastr ID- -- bispeuser Coatainauwrt Sersstrr(s)_ Model: rispower Cantainnient Sensor($). [Dispenser S'hcer Val1Dve(r). []S4aperew Valvc(a). DispenseContainment Float(s)and Chain(s). C]t*xnscr CwtainnmM Flm gs)andChain(,). : t Diw @.Disp=cr Cannot Scnsor(s). Model: ,� ,,M� P�spnms�Cont aFnpAettt$esnsgr(s} Model:shearvalve($). ❑ShearValve(s). Dispenser Ccmiainm f Floats)and Chain(s), LE]Dispmer Cot %intnent mat(s)and Chain(s). "Ifthe facility cxultainS More Mab or diSpta gas,copy this tom, liidude in6rtrafion for every twtic arrd dispenwr at the facility. C- Certification-I certify that the equipment fdentined int this document wan igspec'trdfaerniced is aacardssrme witk the mnufacturera' guidelines. Attached to this Cartifiratioa is information (c.g, manuficturers' cbeekfish) neclaury to verify that this reformation is correct aad a g►te-Piot Pian showing the layout of mcmiturnng t�tent far any eek t capable of genera sue reiw ,16eve W50 attached a ropy of the report:(check a U that afiro): Syst'�W wt-Up �rm hkrWry repo LX3+L" Technician Name(putt): Tony Fontana 5iw.lature: Cei-ti�cation Nom:- V.R.A7.,3086 ICC$2892274JT Lintas:.No.: A-846 Testing Company Nana- U.S.T. amen Testing lite. Phone No.:(209) 596-440 Testing Company Address: R0-Box 580 C9M CA 86307 Date of TwAitl &rvicirigr5!� � TJN-63G—7/� PIWW.IERAIpey.O`Yr