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KA MONITORING SYSTEM CERTIFICATION 1'7 2008 /-or t/se By , ll/ Jurvscliclions 117/hin /he .S'lale of C'crli/irrnia Ailthorily Cited: (7hal-Ver 6. 7, Heallh and &ffel), Code; Chapter /6, Division 3, Tille 23, s This form must be used to document testing and servicing of monitoring equipment. A separa Ptiili`3`/n19�rr, 4-6)ort ntust 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 mist subinit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name:L�Ji4TErCLyt� ! ®O� f f -a C L BIdg.No.: Site Address: 3d r ",q -7-6 Ce --C-00 City:�Q i ��f Zip: Facility Contact Person: j�i�cJt✓ Contact Phone No.: ( 2C"t Y4.4 5'rj / CO Make/Model of Monitoring System: .,I&C3 n.i '7-25 10r-> Date of Testing/Servicing: 4'► / ZC// B. Inventory of Equipment Tested/Certified ("h n.d. tin a nnri ntn hnrnc to : ilii •, t.. ..: r.. ....,f :. .. t...U.•.....,.,.,.d. z nk ID: ?Tank ID:I In -Tank Gauging Probe Space.or Vault Sensor. FW Model /►? � 4w Model• %rt�S Pef-S' <ln-Tank Gauging Probe. Model:AG-Afmular nnular Space or Vault Sensor. Model: ��CPiping Sump / Trench Sensor(s). Model: TS 7 u e_ S' iping Sump / Trench Sensor(s). Model: &p 04-5 Fill Sump Sensor(s). Model El Fill Sump Sensor(s). Model: �9echanical Line Leal: Detector. Model: DLD Mechanical Line Leak Detector. Model: _ a,� ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill/ High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa a 2). ❑ Other (specify equipment ty e and model in Section E on Page 2). Tank ID: 9 C Tank ID: ❑ In -Tank Gauging Probe. Model: 1"Al-G El In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 5 PC i 7`- '7;,fi L/-- ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: 7' /L S ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: — ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Ra- t ❑ 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: ElOther (s ecify e u meat ty a and model in Section E on Page 2). ❑ Other (s eci aui ment type and model ' ection E on Pa a 2). Dispenser ID: % 7t- Z Dispenser ID 3 f -% ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: UG 5 ❑ 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: UG- �' ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 13 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). 11 L, ,x,11 j .1-nr110 unno unM5 vA urbljcusciZ01 cupy uus rU1111. ,ucuiue mrormauon 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): 44ystem s -u Alarm history report Technician Name (print): -i,vr- Ali,23mO Signature: VU �ii 5 2 5; 33 f7 U T Ceilification No.: 1j 3 License. No.: [3rrI Testing Company Name: Phone No.:(6C )'71 - d &.z Site Address: s, Date of Testing/Servicing: l ZY/ 08 Page I of 3 03/01 Monitoring System Certification A Results of Testing/Servicing