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Q For Use By,411 Jurisdictions Within the Stale of Cal- arnfa Auzhorzty Ctted: Chapter 6. i. Herlth and Safer, Code; Chapter I6, Divr_sion 3, Mie Z3, Cakfarnia Code ofRegzclezions This form xrust be used to document testing and ser king of mouitormg equipment. A seaaate eertizication or report au>Yt be A zet7ared far coca motitortz sy° control panel by the technician who performs the woLiL A copy of this form must USTT=syste d to the- Q system owner/operator. The owmr/operator must submit a copy of �s form to the local agency regulating days of test date. A- General WbrmadOn° �i Bldg. No.: Facility Name:. ��zip: �h• --- d C' Exa �.t ? c' Site Address: /11 `77 t/%„�' mit Faailit:y Contac: Person:. `i. -AI Cantact Phone No.: 2L C ) r 3 9- ' /S Maice/iVlodei of Vi onitoring System: , l-i-ct 5 ,' i C Date of Tesiuxg/Se:viczug: % / / L�' B. InventmT of Equipment Teste3/Certified r•,..«u ♦hn—nrnerrate bGX9= to indicate spealfic e>lnipnsmt it1SPeet Tank 173: l �3•In- Tank Gauging Probe. Mode?: r Annular.Spacc or Vault Se -Sar. Model- ` Piping Sump / Trench Sensor(s). Model: C3 yili Sum Sensor(s). Mme: Nfec.4anical Line Leak Derector. Mode?: es ele -ft- 0 ff cQ Elecaonic Tine Leak Detector. Model: .GrTank Ovarml / High -Level Sensor. Model: © Other (saeafy equipment tya and nodal is Sewn E on Pate 2). T=k 2D: Y/ Tanis ID: ❑ In -Tank Gauging Probe, Madel: Rr In -Took Gauging Probe. Model: i? :•• 9' Annular Space or Vault Sensor. Model: d f' 0 Piping Sump / Trench Sensor(s). Model. H �' 0 FlI Sump Sensor(s). Model: yr d JZ meehaniaai Line Leak Detector_ Model ,e C: E C3 Electronic Line Leak Detector. Model: f fd Tank Ove 611 / II- igh--Level Sensor. Model - E3 Ouse• (sUecify �Am=t ty—m and model in SecIIon au Page 2).� ❑ In-T=k Ganging Probe. Model: Tanis ID: ❑ In -Tank Gauging Probe, Madel: CI Annular Space or Vault Sensor. Model• 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: Seor(s). Model: Cl Piping Sump / Trenca ss Model: Fill Sump Seasor(s). Madel: CI Fill Sump Scusor(s)_ 13 Mechanical Line Leak Detector. Model.- 13 Mech2nical Line Leak Detector. Model: Model: 0 Eleczrotsic Line Leak Detector. Model: Cl . Eieclronic Line Leak Detector- ❑ Tank Overfill / High -Level Sensor. Model• Ch Tank Ove. -till / High -Level Sensor. Modch ❑ Other ( ecty equipment itype and model in Sema E on Pa a 2). ❑ other ( ecifym a rod model in Ses•don P. on Page 21• Dispenser ID- %/ Z .� Dispenser Containment Sensor(s). Model w !y Dispensw M: _ Dispcpser Containment Seasor(s} Model: � � '' Shear Valve(s). ,zf Shear Valve(s). Cl Dis arses Containmmert Floats Cad Chain(s). ❑ Dispenser Containment Flo s) and CSaiu(s). Dispenser ID: jI L ,��_ Dispe:sser Coatairunept Sensor(s). •Model: ,,., i � rs •.•. Al IA: ____ 7Y�� ri )• n"`-' Dispenaser Contaisssnent Senso s �+hodel: � '� Sheri' Valves). yid` Shear Velvets). CI Di ser Containment Fioat(s and s). ❑ Dispesnser Containment Fiaat(s and Ctain s . Dispenser ID: ❑ Dispenser Containment Sensor(s). Mode-- Dispenses ID: ❑ Dispenser Cont Sepsar(s). Model: ❑ Shear Vaive(s). ❑Dispenser Ca' awe a cnt Flo s and Chain(s). ❑Shear Velvets). ❑ Dispenser containment.Float(s) and Cham s). *If the faelity contains more tanks or dispensers, Copy this form. include information for every tank and dispenser A Me facility. C. Certification -1 certify that the equipment identillerl in thin document was inspected/serviced in acxnrdanes with the nuauafastnrers' guidelines. A.ttacbed to this Certification is information (e g. nnanufactprers' cheddissts) neeesia y to verify that &is Information correct and a Plot Pian showing the layout of monitoring uplpment. For =y equipment capalble of gen:autiug sueh reports, attached a copy of the report; (check aQ tkatoppTg): a Sy$tem set irp ❑ Alum history, report Teeaician Name (print): AA- blcc/ it!/ir/c+� Sigpatzare• /ti's -`/- Z�''- J - C=fifficzdon No. 355-7 Testing C=M- my NI ame: &S4� t )/ /� /2 Phtme Site A,ddmss: _ �/�!j ......,_L`` „ '? � �f l�"/ Date ofTesting/S�riciow 7 � /? .Monitoring System Certification 2-d 9010-LLE(BGS) P:Qe1 of NUIS1S3M/NUISllU o=/ox dTE r•b0 EO 11 ADW