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!ur ( se Lit,:l!(./ru•isclic•lions 11'jihm II K Stale a/(crliJrn'rriu 3. TNlc .3. .-Irrlhur•ilr C'iletk Chapler•6.7. lkallh nncl Srr/it1�� r(L` Hrr C'uliJnrniu('pc%of Re�ulcdions This form must be used to document testing and servPc�RW1%i VI]BEagtiipment. A separate cer ification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of ti-is form must be provided to perator must submit a copy of this form to the local ages cy regulating UST systems the tart: system owner/operator. The owner/o within 30 days of test elate. A. General Information Bldg.No.: Facility Name: , ttCity: • O Zip: Site Address: I N• EV O ST Facility Contact Person: Contact Phone No.:( L-) 9 1755 Make/Model of Monitoring System: kpp-t -'SISP Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check tine a r ro riate boxes to indicate s recitic c ui mcnt ins ected/sel "c".' Tank ID: S T 0,---TTank IU: I �- loll In-Tank Gauging Probe. Model: MI�'l ) ® In-Tank Gauging Probe. J . t im Annular Space or Vault Sensor. Model: 07-1 91 Annular Space or Vault Sensor. So P Piping Sump/Trench Sensor(s). Model: Rl Piping Sump/Trench Sensor(s). odel: wet 01 Fill Sump Sensor(s). Model: Z�8 Al Fill Sump Sensor(s). Model: Zo8 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: �LI-� 113 Electronic Line Leak Detector.❑ Tank Overfill/High-Level Sensor. Model• ❑ Tank Overfill/High-Level Sensor. lode odel:❑ Other(s eci1 e uiorient type and model in Section E on Pa e 2). ❑ Other(specif a ui ment t e and rndel in Section E on Page 2). "Tank ID: Tank ID: ❑ hi-Tank Gauging Probe. Model- i9 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ___ ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: a Piping Sump/Trench Sensor(s). Model; ?AS ❑ Fill Sump p/Trench Model: UQ Fill Sump Sensor(s). Model: ?pg ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: __ ® Electronic Line Leak Detector. -4odel: � ❑ Tank Overfill/High-Level Sensor. Model:3 _ ❑ Tank Overfill/High-Level Sensor. Model Ll Other(specify equipment type and model in Section E on Page 2). Ll Other(specifyequipment ment t e and model in Section E on Pae 2). Dispenser 1D: I t Z- Dispenser ID: `l T-a ❑ Dispenser Containment Sensor(s). Model: U8 ❑ Dispenser Containment Sensor(s). Model: Zo8 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)andChain(s). Dispenser ID: $-r`l• Dispenser ID:_ Cl Dispenser Containment Sensor(s), Model: ZD8 ❑ Dispenser Containment Sensor(s). A'[odel: Z08 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). [Ll Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 tw __ Dispenser ID: Z-- ❑ Dispenser Containment Sensor(s). Model: _20��_ ❑ Dispenser Containment Sensor(s). Model: ZU8 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy ot�the report;(check all that apply): 112Systemset-u�� Alarm history report Technician Name(print): 7A14f- nil 11MI) Signature: Certification No.: I I P8 License.No.: O -%, Testing Company Name: fF l4-T Phone No j-y—_) I I Site Address: -113 j5L' ADi�o S- Date of Testin Servicing: q � Page I of 3 473/01 Monitoring System Certification A•forda-Test 209 744-0112 416 Ana Street Galt CA 95632D. Results of Testing/Servicing Zane Nimmo C$I_ Lic#04-1676 Dat _ __. ._ —