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Wo NIONiTA.ANG S)'STEM ('EAUIFICr _ ON For Use BY All.1m isdirtions Within the,Stale of Califomin An►hority Cited: Chapter-6.7, 11ralth nrrd Safety(•odr: Chapter 10, I)ivision i, Title 23, C'nlifonrin Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A Separate certification or EWW must be prtpared for each monitoring system control ygnel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/opernior must suhmit a coliv of this forrrr to the local agency regulating UST systems within 30 days of test date. 202 A. General information Facility Name: — L4 v? � - Y'�f rj -- ----- — - - Bldg ft: LSH Site Address: �l 1l D k2 C a r ll �'Y ►t�ot.r City: S_I_'mc'� �l �� -------._..1...-- - --- �----- - ZipPl�g-a n to -S Facility Contact Person: /� r , Contact i Bone No.: ( a0 ) '� 6`- 7 '1 F77 Make/Model of Monitoring System: 6-4-11 G_- C_ bale of Testing/Servicing: 3 /oZZ/ O� B. Inventory of Equipment 'Tested/('erlified i (deck the approate boxes to Indicates ethic a ul)nrcnl Inn uclrWeer viced: Tank ID L1t� -Z Tnuk11► t.i f_� c� 0 In-Tank Gauging Probe. Model _ D - Z�OLL't�/- U In-Tank Gauging Prole. Model: O Annular Space or Vaull Sensor. Model: .-<[OQ� U Annular Space or Vault Sensor. Model:t(-�/J ❑ Piping Sump/Trench Sensor(s). Model: U Piping Sump/Trench Sensor(s). Model: 0 F11 Sump Sensor(s). Model: Li 17ili Sump Semor(s). Model: O Mechanical Line leak Detector. Model: _ U Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model - _ -_ U Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ U Tank Overfill/Iligh-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). U Other(specify equipment t and model in Section E on Page 2). Tank ID: _ —-_-----__-___ _- Tank ID- U In-Tank Gauging Probe. Model: —_ U In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model, _—. _ _ U Annular Space or Vault Sensor. Model: �- ❑ Piping Sump/Trench Sensor(s). Mcxl . U Piping Sump/Trench Semor(s). Moder- O Fill Sump Sensor(s). odel• U fill Sump Sensnr(s) -'Tvtodel: O Mechanical Line Leak Det or-' Model:._ U Mechanical Line Leak Detec. Model: O Electronic Line Leak t£ct', Model:- U Electronic bine Leak,WTeteclor. Model: ❑ Tank Overfill/ Ii Level Sensor. Model: ._ __ U Tank Overfill./N(gh-Level Sensor. Model: ❑ Other(a ui ment type and model in Section E on Pae 2 . U Other(s Ccif equipment type and model in Section E on Page 2). Dispenser ID: `i5 �- Dispenser ID: O Dispenser Containment Sensor(s). Model:/'2AVQVPj1D U f rispenser Containment Sensor(s). Model: - 0,, 1 f{ ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment flont s and Chnin(s). U Dispenser Containment flont s and Chain (s), UMperoer IU: /f ---_._.._.._...-.. ---. .. .-. .. L)Ispenser 111:_ ?_�_—. E3 Dispenser Containment Sensor(s). Model:1p�D7�9?�tt05M/T U Dispenser Containment Sensor(s). Model: L�7t ��tnC'7 O Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain (s). Dispenser ID:_ __ �1 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model.-.I�,.�_---__, _ - - U Dispenser Containment Sensor(;).-Moxki ❑ Shear Valve(s). U Shear Valve(s). 1717is ser Containment Fl i S and Chain s'. W Dispenser Contairlt:c:rt Float(i)and Chain (s). off the facility contains more lanky 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 hnspected/serviced In accordance with the manufactwei ' guidelines. Attached to this Certification Is Informatinn (e.g. manufacturers' checklists) necessary to verify that this Infornatlon Is correct and a PIM Plan showing the layout of monilorluR equipment. For any equipment capable of generating such reports,I have ahto ■Ruched a copy of the report-(chick all that apply): U System set-up U A r hist rreport, Technician Name(print): yl t r AI 17 t ft Signature: __L� / 0 Certification No.: �'��t�c7DL�Ot1-- - License. No. Testing Company Name: _ --- ---s-! _._ Phone No. Site Address: Date of'Testing/Servicing: 1'nRe I of� 03/01 MonllorinR System Cerlificnlion