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Iv-"JINK a kJ1`11vkT 0 1 0 1 U' 1Vll k-111-K li It'lk_ A 11(jN For Use By All Jurisdictions Wi[hin the Stat &fCalifornia Authority Cited: Chapt 7, Health and.Safety Code; Chapter 16, Divisi Title 23, California Code of Regulations 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 date. A. General Information Facility Name: (ail K)6 °�—i0C_OC-TOO AA.,t Bldg.No.: Site Address: 0 0001 `-+tMSX3,.3 27 City: S'TZc�Tt`� r' zip: QiSZ36 Facility Contact Person: `I f C P i C A Contact Phone No.: (`9 L q ) 963 Make/Model of Monitoring System: 6 i3uJ A_i 6'�W i 1C 29- Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicatespecific a ui ment fnspected/serviced: Tank ID: 1 1 te. J Tank ID:-2 2t:�iC J f'� A�c: acts i AaJit EX In-Tank Gauging Probe. Model: rs P L✓L?_ In-Tank Gauging Probe. Model: -T'S t'-L L'- f Annular Space or Vault Sensor. Model: 7-5 P i1L J Annular Space or Vault Sensor. Model: -r5Py Of Piping Sump/Trench Sensor(s). Model: 5 Q Lr L-S ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify Squi ment t)M and model in Section E on Pae 2). ❑ Other(s if ui ment tXE and model in Section Eon Pa a 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(s 'f Squipment tM and model in Section E on Pae 2). ❑ Other(s f Sguip=n!.!2Te and model in Section E on Pae 2). Dispenser ID:TRAW)A-104, rvr Dispenser ID: 'E C t_- S c vn (Dispenser Containment Sensor(s). Model: 229 TELLS' Dispenser Containment Sensor(s). Model: TSP C O ❑ Shear Valve(s). Shear Valve(s). ❑ DisM2ser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Float(s)and Chain(s). ❑ Di!p2nser Containment Float(s)and Chains. *If the facility contains more tanks or dispensers,copy this form Include information 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 equipment. For any ble of generating such reports,I have also attached a copy of the r'port;(check all that apply): 0 System set-up a story report. Technician Name(print): 1�tL t-W �'a-iii.: Signature: Certification No.: 'fad 4'5-80 3760, License.No.: LS 1283.�T Testing Company Name: `i Au t- -Ti m Qc Phone No.:( uS > Fad ' o"c- 1 Site Address: Z_114y , ,v4 €�vC . *8 Vcss wA CP, ci3ex;3 Date of Testing/Servicing: 7 /07 Page 1 of 3 -03/01 Monitoring System Certification