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�1-01ECove MONITORING SYSTEM CERTIFICATION For Use By.411luris'dic.ions W7,hin :he State of Caiijvrnsa ` NOV 2 0 2003 utitnrh'Cited: Citcpter o.i, Health and Safety Code; Chapter:h, Division 3, Ttle 23, Calijornia Code bRegulations This [orm must be used to document testing and servicing of monitorin ENVIRONMENT H ALTH g equipment. A se crate ceniIication or veno ES 1br each monitorin« system control nanel by the technician who performs the work. A cent' of this term met be provided tot eta system owner/operator. The ownentonerator must Submit a copy of This form to the local llency re .slating UST systems within 30 days of test date. VIA A. General Inforr>aation aSS� Facility Name: . t ,'cr'c l`;r Bldg_ No.: �l Site Address: S r t city: ST_cc_ h?� zip: �� :., Facility Contac Lrson: 1,71:-kI C L S^! ( Sz Contact Phone No.: ( )_ Make/Model of Monitoring System: j4Z( QiU 7—J- 1660 Dat�e�ofTestina B. Inventory of Equipment Tested/Certified Check thea rn nate boxes to indicates chic ui ment ins serviced: Tank ID: E Tagjk ID: Z L.0✓J - ark Gauzing Probe. Madel• t3_>7Tank Gagging Probe. ular Space or Vault Sensor. Model: TS P /-r'/ � .],,Annular Soace or Vault Sensor. Modd: �Pipin;Sump/Trench Sensor(s). Model: ✓l L.S iping Sump/Trench Sensar(s)_ Model: ❑mill Sump Sensor(s). Model: ❑ Fdl Sump Sensor(s). Model: r�%lechuni.al Litre'._:al:Detector_ Model: °_: ".)S�f fi r*Mcchanical Line Leak Detector. Model: I t L• -Oj—/ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detecmr. "viodei: ❑ Tank Overfill/High-Level Sensor. Model: ❑ 'Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv equipment.vee and model in Section E on Page 2). ❑ Other(specify equi trent tvDe and model in Section E on Page 2). Tank ID: Tank ID• ❑ Fn-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Ll Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ca-Mechanical Line Leak Detector. Model: ❑ 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(svecify equipment type and model in Section E on Page 2)_ ❑Other(s eci a uipTent:IM and model in Section E on Page 2). user ID: / Z. D'spe er ID: 1 ff Dispenser Containment Sensor(s). Model: L f Y3�spenser Containment Sensor(s). Model: T S - � t S, Cr' bear Valve(s). of Shear Valve(s). ❑ Dis eraser Containment Roat(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). t D��i�sTenser ID: �' Dispenser H): t '3.Dispenser Containment Sensor(s). Model: /—SW`eA tj ❑ Dispenser Containment Sensot(sl. Model: Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser-I'D: Dispenser ID: ❑ Dispenser Corwinment Sensor(s)_ _Model: ❑ D•tsy--aser Containment Sensor(s). tiiodel: ❑ Shear valve(s). ❑ She:r Valve(--). ❑Dispenser Containment Float(s)and Cbain(s). C1 Dispenser Conwirtmcnt Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every rank and dispenser at the facility. C. Certification-I eertify that the equipment identified in this document was inspeetedlser-�ieed in accvrdanee with the manufatAurers' guidelitu!s. Attached to this Certification is information (e.g. manufacturers' cheddists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equip=ent. For any equi at�n�t capable of generating such reports,I have also attached a copy of the report- eck all that apply): Olsystern set-up ist�re t Technician Name(print): SI rr1 Signawre: Certification No.: 0 Lo `( 2-6 ey L cense. No.: Testing Company Name: � f 2 T.�,t'//c I-,S//AS• Phone No.:(��dt ) 6 Site Address: I '3 G4--`7 SAC,,4 `1 f'7r'3 ?c f'/Date of TestinrServicin_: < < < Page 1 of 3 03/01 Monitoring System Certification