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12/11/2008 12:18 FAX SJEH 10001
<br /> 1.Vd`1NI,®,IJRILVET SYSTEM. (."FRTI YCATIO
<br /> h)i-the 1tv:ill Jurisdictions Within thN.Salic of(-'ulAforniu
<br /> Authoril.v(:7hdtl:(:'lrcrpler 6.7, l A,olth ontl Snfet),("(We: Chn/itev 16, I)ii,.i,l ktu 3, Ti/%e 23, C'ali/urnkr Cutle u/Rc ululiuus
<br /> 'f11is farm must be nSCd to CIUCL11110lt 1esti112 and servicing of'tuottitol-inly equipment. A_Sc11kintle cuid1icntitm or report tout;! he
<br /> 1cp;nud for each multimrina system c(ntrul pime'I by thr technichin who pulorins the work. A copy oFLhis iorm mmit Etc providcd to
<br /> tilt:. t,1111% ,4ystcnl owner/operator. 'flim owner/ul i,mitor must Submit a copy of this forst to the local agency regulating LIST systems
<br /> within 30 dugs of test(late,
<br /> A. (relicril Information _
<br /> Facility Name: t-"�� 1 f�)_C��I) ....._....�—# ('�ll.?��i Bldg. No.:
<br /> SIte Address: 122 7 (��(''`_,t: VC..?fit ir?f 1 ('ity: i�2� }, 7,iP: _.
<br /> Fla:ilily Contact 1'e1s011: _. ._.____...__ Contact Phone No.:
<br /> Nlakc/Modal of Monitoring System:'T3 1t)00 A K _...._ . ... Date of i'estinp,/Servicing:
<br /> li. inventory of Fquiil'ment Tested/Certified
<br /> Check the sflpro riale time•s to imlir:itc specific et ui ment ins eeted/servleed:
<br /> Tank 11): Tt nk ID:
<br /> to-Tank Gauging I'rnhc. Muriel: 1� L� In-Tank Gauging Probe, Muriel:
<br /> Cil(.Annutar Space or Viut(t Sensor. Model:_.._-.,..._ FL_S Annular Spice or Vmdt Semor. Mralel: (...
<br /> bA Piping Sump/Trench Scusor(s), Model: [/Pilling Su,ut,/Trench Sensor(s). Modcl: (�1,
<br /> ❑ Fill sump sensor(s), Model: _ ® Fill Sump Scttsor(s), Model:
<br /> ;YMetAianical Line Leak Detector, Mode 1: L,),,1 1) Q P'Mechiolical Lina Leak Detector. Model;
<br /> ❑ Eleatrouic Line Lcnlc ncteclor. Model: U Electronic Line Leak Octector,
<br /> U 'rank Overflil 1 High-Level Sensnr. Mndel: - ❑ Tank Overfill/1-ligh-Level Sensor. Model:
<br /> U Other(SPC6ly ck ui nmol 1. 1e nod urixiel in Section I'nil Pa}!C?.). U l)tht r(s Bell' c ui>ntuttt t x:and ltiodef itt Section f?on P:i a 2),
<br /> i _ Tank ID:
<br /> �dI �ank(jp, ing,llr,(A , Model: Miq!- ... Ulit-Tnnk(iaugingl'mile. Model•
<br /> Atiuular Splice or Vaidi Sensor. Model:_„•,_, ('L; U Annular Space Or Vault Sensor. Model:
<br /> CVI'ip1ng Sump/Trench Iwnscir(s). Mudul: ❑ Piping Smnp/Trent l Sclt or(,). Model:
<br /> ❑ Fill Suutp St;tlsor(s). Model; - _ U pill Stump Seasur(s). Model;
<br /> P/Me01111flGill lieu Leak Delectur. Modeli 7j4 ❑ McL'Itunicu) Line Lenk DetCctur. MUdCI:
<br /> U Plectronic Line Leak Detectur. Modcl: U Electronic Line Leak Ducetnr, Model;
<br /> ❑ Tank Overfill/l lig;h-Level Serial•. Model: U Titnk Overfill/Iligh-Level Sensor. Model: _ . ..
<br /> E3 Other(s et i(y a ul ment 1 e and tittxlel in Section P•on 1'n a 2). C1 Other(s ci(y a ui ment ty a and model in Section L tltt
<br /> Di pensee ID: t z p_ Dispenser iD: Z,
<br /> I)itipenver C'atlluinmcn1 Sensor(s). Model:. la_`�._ Dispenser Coninilimunt Seusor(s). Model:
<br /> U Shear Valve(5)• L.1 Shear Valve(s).
<br /> * Dispenser Containment floul.(s)and Chain(s). _ ❑ Dig t'nser Contiiiinmeni Flont(s)mid Cl ttin(s)_
<br /> Dispenser IBD: F 4 i_:>
<br /> )ispanser C Ontillottlellt SCItSUr(5), Model: U(,�j DiupeuseC'ontatiuuent tit:nsar(s). Morita: !,/L_ 5
<br /> ❑ Sheur Valve(s). ❑ Shear Vsllve(s),
<br /> ILl
<br /> Dis wnscr Coiitui ntllCltt FIoat(s)and C'hain(s). U Dir; nSOt'C'ntltaiunicnl hlctat(s)alta Chain(S),
<br /> ispen.crr 11):_�_ _ _ n6penser 11):
<br /> Dispenser(:onlainntell1 Semsm(s). Model: ❑ L)isprnserC'nntainmcntSensttr(s). Model:_
<br /> ShearValvc(s). U SheurVulve(s).
<br /> Dislellser('ontninrnenl Floitt(S)and Chuin(S),
<br /> Q Itis ogee('pnittinulcnt floats}and C.'ltain(s).
<br /> *u'the raeitily cautains marc tanks nr dispensem,copy this lbrnt. include inibrntation for every tank tend dispenser td the Alcility.
<br /> C. Cordfleatioll certify deet the equipment identificd in this docuuaenl was iltspected/serviced in accordance with the
<br /> manufacturers' gnidelines. Attached M this Certification is information (e.g. manufacturers' ChecklLsts) nece.ssm-3' to verify Ih:l( this
<br /> infrlrm;ation iv cur'reet and a Plot Plain showing the w,out or monitoring equipment, For any equipment calinhlc of gencraltint; sarcla
<br /> reportH,I have also;attached a copy or the report;(rheck all thal typlv): C1 Sy (C set t Ahm istol• 't
<br /> TachniChIll Name(print): Felix Ralnirca Signature;
<br /> � r
<br /> (':ertit`iCation No.: '�=? i 3� _�... . License.No.: _ TTI,#Oft-1740 1GG#S
<br /> Testing Company Name:_Ja� � i7i?�• �'"'_�_� _ 'Itnnc No.:� 0112
<br /> Site Address: _., I)nlc of Testing/Servicing;12 ht� �U�
<br /> Page I ot•,I ua/all
<br /> Monitoring System Certification
<br /> U. ltcslllLs of'!'estil4g/Selrticinry
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