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11 WOTORING SYSTEM CERTI CATION For Use By All Jurisdictions Within the State of efornia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 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: STC3CKT6VJ AS, Bldg. No.: Site Address: 2000 C; --i- l eASC 'j 'R City: S-t-tsCx-i-o k Zip:'SLC�Cc' Facility Contact Person: 5c 'C'T(ki ' 'i3t CA Contact Phone No.: 3 � Make/Model of Monitoring System: E &Y-) AUAD -S-T. i K .3 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 'i r s!'_I a lC Tank ID: T aJ lc- Z- 2 r t( CdIn-TankGauging Probe. Model: TS,P -lL% ( In -Tank Gauging Probe. Model: 'TS - EEL I. Annular Space or Vault Sensor. Model: TS? -0k O_Annular Space or Vault Sensor. Model: s 5 - U ai Piping Sump / Trench Sensor(s). Model: _ j S? - 11t.S ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: O 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 (specibLSqqipment.type and model in Section E on P e 2). 0 Other (s if Equipment t)r and model in Section E on 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: O 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 -Levet Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other �sBEER Squi2T22LtM and model in Section E on P e 2). ❑ Other (s if 29uipMSRL!Loe and model in Section Eon Dispenser ID:'TP AOS, UDC_ Dispenser ID: RCCL Ubc..- WDispenser Containment. Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). ❑Dis user 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 Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). L3Di!penser Containment FloatKg and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). *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 eqMp7pabijof generating such reports, I have also attached a copy of the rert; (check all that apply): IR System set-up report Technician Name (print): CC --W Gpi— ioDu Signature: Certification No.: O Li i' C>0 -1r. I t License. No.: Testing Company Name:`rAi.,ii -1 +0C Phone NoA BOS ) L -S 6 " W6 Site Address: Z 7 y J 5AzeuLlo &v, 46 \(6 kAU q;A + e- c'900-3 Date of Testing/Servicing: 8 / tt ok- Page 1 of 3 03/01 Monitoring System Certification