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re By A11./urrsncclions 1i'irhin!/r .Dale of C m rior lullrority C filed: Chapter(.i, 4llealth and S«fely Code; C'hapler•I(, Division 3, Tille'3. Califnrrria Code of i1c u4rrion.t This form must be used to docurnent testing and servicing of monitoring equipment. A seaarate c Dr � , be prepared for each monitoring ystem 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 agent AIttg•t[�,�,�Luu systems within 30 days of test date. f' - A. General Information ENVIRONMENT HEALTH Facility Name: <-Y_KM,A-r-V— VAIey'n P 1T1'&Enyff Site Address: `J)? �). '�/ j9b Atm ,r..1 City: Zip: Facility Contact Person: rY,0 rl A-r l W1.e d Contact Phone No.:( ZU ) y'�j�- /;U7j— Make/Model of Monitoring System: TI,S -?SD Ve-'?Je f VZ�r 4!� Date of Testing/Servicing: _V/2�91 Qp B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eouipment inspected/serviced: Tank ID: ,F7 Tank ID: p In-Tank Gauging Probe. Model: /71st W In-Tank Gauaing Probe. Model: IY A 6 1, 0 Annular Space or Vault Sensor. Model: �Q L is Annular Space or Vault Sensor. Model: 3U i ® Piping Sump/Trench Sensor(s). Model: '�0? ® Piping Sump/Trench Sensor(s). Model: * Fill Sump Sensor(s). Model: a G A Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: .(1(> ® Electronic Line Leak Detector. Model: l 10 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Page 2). 11 ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: (�, 0a Tank ID: N In-Tank Gauging Probe. Model: MAh ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: SPOT ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: ZDV ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: Z V ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 1 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui ment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). " Dispenser ID: )' Dispenser ID: 3 '�S► �/�ispenser Containment Sensor(s). Model: LOF _ Dispenser Containment Sensor(s). Model: Z pk lL shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: .6 Di enser ID: 9/Dispenser Containment Sensor(s). Model: li0 Dispenser Containment Sensor(s). Model: z Shear Valve(s). .@Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). LIDispenser Containment Float(s)and Chain(s). Dis enser ID: Dippenser ID: /tel 11 rspenser Containment Sensor(s). Model: Jr"}�ispenser Containment Sensor(s). Model: 7 -QeShear Valve(s). 'Mshear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *Ifthe 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 of the report;(check al/lhat apply): 0 System set-up ®Alarm history report Technician Name(print): y;i'7 [ Signature: 1__„j Certification No.: 3 5� License.No.: lf�L- L!T Testing Company Name: n r b A �5'T Phone No.:( joq 7:14, 6//Z Site Address: 7 J 3 /J_. G IID o'(.A o f;1 Date of Testing= Z /Servicing: Page 1 of3 03/0I Monitoring System Certification D. Re,'-'RWs ofTe.,.; oRg/ytrrvicing