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MONARING SYSTEM CERTMA nON RD ECE�WE�FD�' For Use By All Jurisdictions Within the State of California oo� Authority Cited:Chapter.6.7,Health and Safety Code, ter.16,Division 3, Title 23, California Code ea This form must be used to document testing and servicing of monitoring equipment.A setsarate certification for each monitoring stem control panel by the technician who performs the work. A copy of this form must q $ &k system owner/operator. The owner/operator most submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. neralto, tion Facility Name: W L S T /--A M 4! F-Lt 6-l-5 Bldg.No.: Site Address: -3 3 0O t�3., L-A N E City: 57'ei C k'7-O 40 1, c-4 Zip: Facility Contact Perm: U#r1-l L n A7 H Contact Phone No.:(2 O l j -/6,2-S'7 07 Make(Model of Monitoring System: VEE iQ2 `t-L.S- - eOQ C Date of Testing(Servicing: /,'/ 2YI 6 3 B. Inventory of Equipment Tested/Certified Check the a tobmaito l"ndlente Tank W. Tankmt 371p Tank Gauging Probe. Madel- ❑In Tank Gauging Probe. Model: Qr'Ammlar Space or Vault Sensor. Model:---79Y-3 tC-'Y2- ❑ "nular space or Vault Sensor. 1: Piping Sump/Tich Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). M ❑Fill Sump sensor(s). Model: ❑Full Sump s). Model: ©-techanical lane Leak Detector. Model: -5 7-,-0-ria L ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: • Tank Overfill F High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other�spec Mipment=and model in Section E on EM 2). ❑ Other Lsgecj mant=and model in Section E on Pa 2). T ID: r - .'5 Le 6f--A-a 4 Tank ID: lo,Tank Ganging Probe. Model: / / ❑ In-Tank Gauging Probe. Model- War Space or Vault Sensor. Model: -5'Z0 Cl Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: -7 4`r`--4 TfO-;Z(5 Y O Piping Sump/Trench s). Model:- ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 3Mecharucai Line Leak Detector. Model: tit D ❑Mechanical lane Leak Detector. Model: ❑Electronic Line Leak Detector. Model ❑Electronic Line Leak Detector. Model: • Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/ -Level Sensor. Model- ❑ Other( at DE and model in Section E on Page 2). ❑Other(!ma===and model in Section E at Page 2). DispMer ID: I— Z Dkpemw lik -7-N Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O'Shear Valve(s). Ershear Vaive(s). Containment Floats)and Cham(s). Urbispenser Containment Float(s)and Chains . Dispenser if): Dispenser II}: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: (nbear Vah*s). ❑ Spar Valve(s). Containment Float(s)and Chain(s). ❑ Ris yenser Containment Float(s)and Chain(s). ffiRrES'�hZw ).,6 Ic m, Dispenser Containment s). Model: ® Containment Sensor(s). Model• ve(s). ❑ Shear Valve(s). Containment n2-As)and Chain(s). ❑ nser Containment Floats)and s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. Attached to this Certirwation is information (e g. of ) neoessary to t this information is correct and a Plot Plan showing the layout of monitoringFor any capable of I e also a a of tete •(check all apply): set A hWory report Technician Name(print): AI-V tJ L A41(-L944W Si Certification No.: I License.No.: Vo Y-V?a Testing Company Name: CHAAPi64 aec(Sfbl) 14tux IZEi7'it^-t'r, Phone No.:( SOa) G(oo - C13 Site A be W OX J'3-D5'2 S//7CA% e/i P Date of Testing/Servicing: Page 1of3 03ffil Monitoring System {I I