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GNNG SYSTEM CE TIF TI N or C/se Bv.4HJtrrisdiclions if%itliin ihe.Sltile gf'CciliforviicI 1 uthorily Cited: Chapler 6.7, Heallh ctnd Sgfety Code; C'hapler /6, Division 3, Title 23, California Code of'Regarlations 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 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 dates A. General Information Facility Name: 9:--TTL-C--M MN U"ason1 Bldg. No.: Site Address: 601 e• ryi� City: L, 017 j Zip: '75.2-V6Facility Contact Person: p Contact Phone No.: (rL) Make/Model of Monitoring System:—&a64Jr —/L!5— "FltO Date of Testing/Servicing: /16/ D:�- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecine Ta k ID: OG.'"f Dis enser ID: _ q •f- t 02ispenser n -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r P' ing Sump / Trench Sensor(s). Model: ill Sump Sensor(s). Model: 'l p ❑ Mechanical Line Leak Detector. Model: eZIE-lectronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (secif equipment t e and model in Section E on PaLe 2). Ta - k ID:ou -Tank Gauging Probe. Model: anular Space or Vault Sensor. Model: ping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ jvtechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: l 4- Z' -Dispenser 0 Containment Sensor(s). Model: Ja? Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dis enser ID: 3 d-tf Pf Dispenser Containment Sensor(s). & Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID 5 ¢ dDrspenser Containment Sensor(s). dJ Shear Valve(s). ;Dispenser Containment Floats) and TaWk 1 D: pC-I- 1.412 n -Tank Gauging Dis enser ID: _ q •f- t 02ispenser Probe. Model: 6( anular Space or Vault Sensor. Model: p Pipurg Sump / Trench Sensor(s). _ Model: $ ❑ Fill Sump Sensor(s). Model LIL,Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on PaLe 2) Tank ID:5eL -- fdl -Tank Gauging Probe. nnular Space or Vault Sensor. Model: 6f XJ Piping Sump /Trench Sensor(s). .Fill Model: Zo Model: �U$ Sump Sensor(s). Model: O ❑ Plechanical Line Leak Detector. Model:-�� ,@Electronic Line Leak Detector. -�—� Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pave 2). Dispenser ID: -7+93 oEDispenser Containment Sensor(s). Model: Ad"Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(,, Model:Q Dis enser ID: _ q •f- t 02ispenser Containment Sensor(s). Model: Shear Valve(s). Chain(s). ❑ D:----- -- Contaironent Floats) and Chain(s). W ®llfc Dispenser ID: It 4 t Z W Model: l3 .Dispenser Containment Sensor(s). Model: _ .®'Shear Valve(s). 'hain(s). ❑ Dis censer Containment Flo•rt(s) AP] ' an i irn(s). *If the facility contains more tanks or dispensers, copy this form. Include inforniation 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 equi meat. For any equipment capable of generating such reports, I have also attached a copy of the report; (check a//1hn1 rrpp/p): System set -u Alarm history report Technician Name (print): ft- wt tASignature: Certification No.: (f License. No.: ® `- Testing Company Name: A — _7 Date Site Address: 60tMa►.t t— Date of Testing/Servicing: '� / talar Monitoring System Certification Page I of 3 .,rl-' D. Results of Testing/Servicing 03/01