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19255517888 Main Fax GETTLER RYAN INC 09-Irl-56 a.m. 01-12-2007 5/11 MONITORING SYSTEM CERTIFICATION5W42 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must 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 systems 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. & General Information Facility Name O is G 0'3 O Bldg.No.: Site Address: 8 S` E �o �. ` City: ka4-1--V2r Zip: Facility Contact Person: /rrte; /"ed" Contact Phone No.: Make/Model of Monitoring System: VeeAr 17- S 3S--D Date of TeMing/Seavicirtg: B. Inventory of Equipment Tested/Cerdfied (leek the appropriate box"to iadieate specific egripmeat isvpceted/serviad: Tank ID: gc} h ICI C�r4Lk Tank ID: O in-Tame Gauging Probe. Model: ❑ In-Tack Gauging Robe_ Model: O Annular Spam or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 9Y 3 80--T'Z-3 ❑ Piping Sump/Trench Seosor(s). Model: Q Fill Sump Smsor(s). Model: ❑ Fill Sump Sassor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Lune Leak Detector. Model: O Electronic Line Leak Detector. Model: 0 Tank Overfill/FGgh-Level Sensor. Model: O Tack Overfill/Higti-Level Sensor. Model: O Other(specify equipmentand model in Section E on Page 2). ❑Other(Specify equipment tYpe and model in Section E on Page 2). Tarek ID- Truk ID: ❑ In-Tank Gauging Probe. Model: O In-Teak Gouging Probe. Model: ❑Annular Space or Vault Sensor. Model: O Annular Spam or Vault Sensor. Model: ❑ Piping Sump/Trench Sev-,%*s). Model: 0 Piping Sump/Trench Sensor(s). Model: O Fill Sump Saesor(s). Medd: ❑ Fill Sump Sensm(s). Model: ❑ Mechanical Line Leak Detector. Modd: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 0 Elaxronic Line Leak Detector. Madel: O Tank Overfill/Higb-Levet Sensor. Model: ❑ Tank OveM/High-Level Sensor. Model: ❑ Other(speeffy equipment type and model in Section E on Page 2). ❑ Other(specify equipmet type and model im Section E on Parc 2). Dispenser ID: ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensm(s). Model: D Shear Valve(s). ❑ Sheen Vdve(s). ❑ Dispenser Contaminant Float(s)and Chain(s). ❑ D' Cacrtammant Floats)and Cham(s). Dispenser ID: Dispenser m: O Dispenser Containment Scissor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Sbcar Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Cantaimucrnt Floats)and Chain(s). Diapeaser ID: Dispenser 1D: 0 Dispenser Containment Sensor(s). Model: ❑Dispenser ConhinmeYnt Sensor(s). Model: ❑ Shear Valve(s). 0 Shear Valve(s). ODispe neer Containment Floats)and Chain(s). ❑ Dispenser Containment Flooks)and Chnin(s). ,if the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenses at the facility. C. Certitfit ation - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufietorers' guidelines. Attached to this Certification is information (e.g. manofactmrers' cheeklisb)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equlp1 to For any equipment capable of generating such reports,I have also attached a copy of the report;{check all tfiatW11y): = m set-v P ��rm history report On ljr L 6 . Technician Name 6;— a anGL,[� Signahne 89 Certification No.: /A—?O /_3 License.No.: ZQ , 3 Testing Company Name:^ � �' ' Phone No.: ZS } S-S—/ _ SJ'- Site Address: _ Date of Testing/Servicing: Page 1 of 3 s3J1?I