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1 For Use BY AH Jurisclielious f I ilhin 1he Slcrte gl'Calijurnin ,authority Cited: C'hcrpler 6.7, Heallh andSufely C'ocle; Chapler 16, Division 3, Tille 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form mast be provided 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 Infolttiation ,,-- // Facility Name: #' - fV H t fia-te t2 �ivoa ,f2�JWD A�(23,r b J Bldg.No.: Site Address: al®B F roe C-9,10/�T 5'T City: S'Teoe-.tr_ro rJ Zip: 9.42 Facility Contact Person: Contact Phone No.:( Make/Model of Monitoring System: VE"k-0 2ocr( -r-Ls• 'g 50 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified C beck the appropriate boxes to indicatespecific ec ui ment ins ected/serviced: Tan ID: DL Tank ID: S In-Tank Gauging Probe. Model: �'(n-Tank Gauging Probe. Model: A�6t nnular Space or Vault Sensor. Model: 1 ❑ Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: 2� �iping Sump/Trench Sensor(s). Model: _gots F Sump Sensor(s). Model: 208 .Fill Sump Sensor(s). Model: aDi� Mechanical Line Leak Detector. Model: 'S'TI�-M Lh ;;k6echanI& CP-Line Leak Detector. Model: CP-lk"I El Electronic Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: C3 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ec ui ment type and model in Section E on Page 2). ❑ Other(s ecify equipment tv a and model in Section E on Page 2). Ta k ID: / 0 C-T Tank ID: In-Tank Gauging Probe. Model: M At6l ( ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: .10$ ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: c2Q5?! ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 16-W-MLD ❑ 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 type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section Eon Page 2). Dispenser ID: Z Dispenser ID; X Dispenser Containment Sensor(s). Model: 20£3 Jk Dispenser Containment Sensor(s). Model: �e�g A Shear Valve(s). }.Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 34q Dispenser ID: A Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: J4 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 54- Dispenser ID: jk Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Ll Shear Valve(s). ❑Di' ' e n ' Containment Float(s)and Chain(s). 11Dis)enser Containment Float(s)and Chain(s). *If 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 equipment capable of generating such reports,l have also attached a copy of the report;(check all that apply): Jiff S U,SO-UP MAlarm history report Technician Name(print):_:Z40d PSignature: Certification No.: J/;?3 License.No.:XU W 524 33a� U 7— _ L 'ti�Q� � Company Name: 0o4 _ c�S i" Phone No.: ,Q09 7-4 - 6&.2- Testing Site Address: 6511$rj E. FeFfA614r ST Date of Testing/Servicing: 5 /2-1/07 Pagel of 3 03/01 Monitoring System Certification A Results of Testing/Servicing