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Oct 22 03 01:32p AL STARlWESTSTAR (559)277-0106 p.2 of O �G SYSTEM CERT ATION For Use By A!1.lurisuacdOns ar7thin :lye State of California 4uy;`iontj Ci:e Cnaptey 6.%Health and Safer, Code, Chapter 16, D�•l=n 3, tate 2�, Cakfornia Code ofl�zgalarions I -his form rrmst be used to document testing and se,^1icing of mouitorimg equipment A seaara=d certitic aton or resort must be Qreaar( for each m2niturirP ,,stem control navel by the techytician who pumas fire wort A Copy of this foam must be provided to theta;. system ownex/operator. The owner/ope: Wtor must, submit a copy of b3is form, to tixe'local agency regulating L; ST systems vWd in clays or t.mt date. A. General Information/q, , FacztiityiVaure:. /�/�//i7 •-•'r✓I/I- Bldg. No.; site Address: 1'G `17 : '11c s� • �+,' � e Cay. Escd L't # zip: �%Sr 3 2 0 �6 Facility Contact P---s=.C L�--�i�- Contact Phare Na.:Z{ G`i' } ,ter•- .3 'Make/Model of ldonitoring System: Date of Twting/Serviciag: B. Inventory of Equipment Tested/Certiflled Tank ID- . 7 Tank 1D: .7/ )n -In -Tank Gauging Probe. Model: i ir: 3 )n -Tank Gauging Probe. Modek C 13---: Annular.Space or Vault Sensor. Modch ' ' ' P' Annular Space or Vault Sensor. Model a r' Pipin.- Sump / Trench Sensor(s). Model: °' ai Piping Sump / Trench Seusor(s). Model: ^ �' iii Sump Sensor(s). Madel: ❑ Fill Sua� Sensor(s). Model: O' Mcc,�on cal Line Leak Detector. MoceL j ar ee t('c !� Mechanical Line Leak Detector, Model: C: Q Ele�onic Tine Leak Detector. Model: Cl Electronic Line Leak Derector. Model: _ .Ca Tank OverffH / High -Level Sensor. Mode?: c . rrr 0 Tank Overfill / High4Avel Sensor. Model: ❑ Other (. =u!gTem and model in Secaoa E an F ec 2). ❑ Other (s.eassiament . had model in Section Tank ID: Tanis ID: Cl in -Tank Gauging Pr obs. Madel: ❑ In -'yank Gauging Probe. ModcL- G :annular Space or Vault Sensor. Model. 13 Annular Space or Vault Sensor. I Model: ❑ Piping Sump / Trench Sensor(s). Model• ❑ Piping Sump ! Trench Sensor(s). Model: ❑. Fill Sump Seasor(s). Model• ❑ Fill Sump Sensor(s). Model: ❑ Mcchanical Line Leak Detector. Model: C3 Mechanical Line Leak Detector. Model: II Electronic Line L=k Detector. Model: C] ETecnolsic Line Leak Detector. Model: ❑ Tank Overfill / High -L --vel Sensor. Model• ❑ Tanis Overfill / High -Level Sensor. Madel. ❑ Other ( ecifv_ equipment c rand model in Section E on ?^ 2). E3 Other (specify ea t and model in Section E on P 2). Dispenser ID: 2- Dispeyyser ID: ,OI Dispenser Containment Sensor(s). Model: 1> ' 3 +,•s Dispe.nsw Contaimnent Sensor(sa Model: f r� Shear Valve(s). ,Q Shear Valve(s). ❑ Di euser Containment Fl s) had Chains . ❑ Dissxas� Coataintyteat Floats and Cbain(s). Dispenser TD: 3r / D" eraser ID: 7 Dispenser Contaiutneat Se csar(s). Made!. Dispenser Coutaiturkut Scnsor(s). Model: Shear Valve(s). ;�' Shear Valve(sj 'J Di cnser Containment Float(s) and Chain(s). ❑ D' enscr Cantafi meni Foots and Chain(s). Dispezaser ID: Dispense ID: ❑ Dispenser Containment Seasor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valves)- ❑ Shear Vaive(s). ❑Dimenscr Containment Floats) and Chain(s). ❑ Dispenser Containtnent Floats) and Cham s). •if the fheity contains more maks or dispensers, copy this form. include information for every tank and dispenser at the C. Certification - I certify that the equipment identified in this document was inspected/s--iced in accordance with the mmamfacturers' guidelines Attached to this Certification is information (eg. zaannfactnress' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any egnpment capable of gmer2ting such reporm, T'aave also attached a copy of the reperr, ("I ez* allffi,& aaplyJ: Ci Spstesn set ifp G' Alarm his#ary report Technician Name (print): �i dpc�� / y�i u�lof% SigaaEztae:1� /�� Certi�iication No.. Lic=39,e. NO.: Testing Company Name: i�.- 7 .S%19x2 P3ane No.. S'S' Site Address: /E f L� ) �r� F 5f . %t'% Date of Testingi'Servic*-: 7 �Y Page I of 3 WAI •_Monitoring System Certification