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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictiom Within the State of California Authority Cited,--Chapter 6.7,Health and safety Code;Chapter 16,Division 3, Title 23, California Coda of Regulations This form must be used to document testing and servicing of monitoring cquipmcnt 4)' -A seoarata,ccrtifieation or report mus Q A arod�or h mo>zitorin¢systsm contryLoa»Q by the t th w BEi4e A copy of this form must be provided to the wik system owner/opesedor. The owner/operator must submit a copy of this forst to the local agency regulating UST systems within 30 days of test date. MAR 2 4 2014 A. General Information ENVIRONMENTAL HEALTH FaciliryNaalo: r�o $idgARTMENT Site Address: IM City: J:�Cdckml Zip. --- Facility Contact Person: Contact Phone No.: ( ) - 'Ma ke/Model of Monitoring System: __-a -3sb Date of Testittg/Servicing: B. Inventory of Equipment Tested/Certified Check tkk6wopriate`boxes to Indicate spedilic cqbIpwent Inspected/serviced - I Tank ED: �[ Tank ID: 0 in-Tank Gogins Probe. Model: Q in-Tank Gaugins Probe. Model: Annular Space or Vault S mor. Modol:*- Annular Space or Vault Sensor. Model: �- Piping Sump 1 Trench Sensot(s). Model: Piping Sump/Trench Seasor(s). Madel: Fill Sump Setwor(s). Model:.$ arS Fill Sump Sms*s). Model: —. ' 9anieal Line Leak Detector. Model: Mechanical Line Lock Detector. Model: ❑Pecbonic Line Leak Detector. Model: ---�� ❑Ateetronie Line Lank Detector. Model: Tank Overfill/High-Leval Sensor. Model:y^1V^} Tank Ovediil/High-Level Sensor. Model: +' t []Other(specify equibkmt type and model in Section B on Page 2). ❑Other(ape 4 equipment type and model in Section 1~an Page 2). TsnktD: q Task 111): ❑.in-Trnk Gauging Probe, Model; W-Tank Gi a+"Probe. Model: _ J, Annular Space or Vault Stow. Modell ❑Annular Space ar Vault Scwor, Model: 0 Piping Sump/Trweh Sermt(s). Model: Piping Sump/Trench Sonsor(s), Model: QJ Fill Suter Scruot'(I). Model; Fill Sump Sensor(a). Model: Mechanical LW Leak Detector, Modal: _ ❑Mechanical Llan Leak Pvtoetor, Model: C]Elwuonk Linc leak Detector. Modal: ❑Electronic Lino i.cak Detconr. Model: ❑Tank Overfill/High-Level Sensor, Model:— � ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment-type and model in,section E on Page 2). ❑.00w(epee*equipment type red model in Section B on Paps 2)- Dispeaw ED: Li Dispenser ID: ❑Dispenser Containment Scttaor(s). Model: ❑Dispenser Containment Sensor(s). Modal: (]Shear Valvc(s). Q Shear Vdvc(e). ❑Dh pcsucr Cootainmalt Ploat(s)and Chain(s). Cl Digx=r Containment 1:loat(s)and Chdin(s). Dia rouser ID; (,,. Dispenser M: ❑Dispenser Contslamat Semor(s). Mod i' 5-----..- .-. 0 Dispenacr Containment Sensor(s). Modal: tri Shear valve(o). 0 Shyer Valvo(s). ❑Dispenser Containment AoWa)and Chain(s). Cl Disperdw Containment Float(.)and Chain(s)- Dispenser ID; -L i Diapamer ID: ❑Dispenser Containment 3cnswr s). Model: 'S.- ❑Dilpenser Cm"inmemt Sensor(s), Model: 0 Sheet'Valva($). 0 Shear Valve(s). ❑Dispenser Containment Float(,)and Chain(s). 0 Dispenser Cotdainment F1oa*)and Chain(s). *Ifthe facility contains more tanks or dispensers,copy this form. Include iuformation for every took and dispenser at the ibcility. C. Certification-I certify that the equipment identified in this document was inspeeted/tervicA in accordance with the manufacturers' guidelines. Attached to this Certitlesdon is Information (e.g. manufacturers' checklists) necessary to verity that this Information is correct and a Sat ELLPlan showing the layout of monitoringIpment. For any egt{t meat capable of generatin such repo 1 have also attached a copy of the report;(check all that apply): �System set-up edj Al2xAoii3tury report Technician Name(print): Tony Fontana Signaturo: Cgdifiodm No.: v.P.A22680 ICC 6289227-UT ^ >:;�� A•8462 r_ I Testing Company Namo: U.S.T.Colrtlpilaance Testing Inc. Phone No.: 209 59641488 Testing Company Address: P.O.Bax 680 Corns, CA 96307 Date of Tesd*Servicing: -1 � UK-AU–!/4 rvxw.aaldomon Rev.08/17108 S: T 'd tStri89tr Cil 96,LT TSS60d 33NCI-IdWO-I 1Sf1:W0dd 22:60 trT03-P-2-6UW