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Moi ,.&l'ORING SYSTEM CERTIFICATION NOV 2 2 2002 For Use By All Jurisdictions Whhin the State of California Authority Cited..Chapter 6J,Health and Safety Cade,:Chapter 16, Division 3, Title 23, CaliforniEUBQW lie s iii H PERM IT/SE RVi'-t This form must be used to document testing and servicing of monitoring equipment, A separate certification or reportmust be prepared for each monitoring system control panel by the technician who performs the work A copy of this form,must 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 Inf ti n Facility Name: C� C7 ��, rf. BIdg. No.: Site Address: 12 City: S7_ , 72TA Zip: Facility Contact Person: 13s-(T,_ ,cwl 757 Contact Phone No.:(__) Make/Model of Monitoring System: Date of Testing/Servicing: 4 B. Inventory of Equipment Tested/Certified Check the appropnate boxes to ffidicate specifle ui ment Ins ed/ser-deed: T.aIKID: �— Taprk ID: i(II -Tank Gauging Probe. ModeI: , / &In_Tank Gauging Probe. Model: 03rj2,S— tfd"Atnular Space or Vault Sensor. Model: / f �/�nular Space or Vault Sensor. Model:�`;E15 Piping Sump/Trench Sensor(s). Model: -tL C S` �ffRe Ing Sump/Trench Sensor(s). -Model: 1[Sump Sensor(s). Model: Sump Sensor(s). Model: �lechanica1 Line Leak Detector. Model: jl��d i`6 chanical Line Leak Detector. Model: /(6' OS ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecifZ equipment t and model in Section E on Page 2). ❑ Other(s eci a ui ment type and model in Section E on Pa a 2). Tank ID: Tank:ID• ❑ In-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: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: . ❑ Mechanical Line Leak Detector. Model•` ❑ Electronic Line Teak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment and model in Section E on Paee 2). ❑ Other(specify equipment t and model in Section E on Page 2). Dispenser ID:__j Z Dispenser ID: 7 j C7 Dispenser Containment Sensor(s). Model: �S�/1 4A L ( spenser Containment Sensor(s). Model: L_ IZ Shear Valve(s). ❑ Shear Valve(s). D Dis enser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). _ Dispenser ID: `9' Dispenser ID: 94P�nser Containment Sensor(s). Model: `S /�- (� El Dispenser Containment Sensor(s). Model: _ hear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment FIoat(s)and Chain(s). Disoenser ID: Dispenser ID; ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear v2lve(s)• ❑ Shear Valv--(s). UDispenser Containment Float(s)and Chain(s). ❑ Dispenser 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 identiCed in this document was inspeeted/servieed 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,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑r.t��hist r ort Technician Name(print): ) CA f Y1�S Signature: Certification No.: License. No.: Testing Company Name i "?,12i a t%/ ;;; yAe Z 7 %r X14 Phone No.:( 90 C1) G 6�� +9YYS Site Address: 9 Ste-,ems, est} e1SW 3-39 Q-Date of TestinJServicing: Page 1 of 3 03101 Monitoring System Certification