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i Oldr NG SYS'IT f CE T,IF A TION se By A11 Jrurisdic7ion.s I- (thin the ,State of Ca/ifoj•nia Aulhorily Cited: Chapter 6.7, Health an(l.S(�/ery Code; Chapter 16, Division 3, Tille 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 w1tfiin 30 days of test date. A. General Information Facility Name: `Q(� 1'001 il Bldg. No.: Site Address: -60 ELStt & �1�-A (CXR cxar�_ City: 5—+0 , Zip. rj Facility Contact Person: Contact Phone No.: ( 2 DCI )AZ - 5g1 Make/Model of Monitoring System: 1 to WN Tf---) [ot Date of Testing/Servicing: (�/US /O`% B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecific ea ninment incnortn.u�a.,,: a. Tank ID: PUL Model: In -Tank Gauging Probe. Model: (� Annular Space or Vault Sensor. Model: '0 Piping Sump / Trench Sensor(s). Model: T5��_ ❑ Fill Sump Sensor(s). Model: 09 Mechanical Line Leak Detector. Model: P_,'T "D LU ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecif e ui ment !Xpe and model in Section E on Pa a 2). Tank ID: X In -Tank Gauging Probe. Model: (� I Annular Space or Vault Sensor. Model:! }- It Piping Sump /Trench Sensor(s). Model: UL ❑ Fill Sump Sensor(s). Model: ffi Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: t' 3 7- % Dispenser Containment Sensor(s). Model: Shear Valve(s). K Dispenser Containment Float(s) and Chain(s). Dispenser ID: t2- g 6 Dispenser Containment Sensor(s). Model: Shear Valve(s). 19 Dispenser Containment Float(s) and Chains Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Dis eraser Containment Float(s) and Chain(s). *If the facility contains more taa?ks or dispenseis, copy this form. Tank ID: '�ESL p DI In -Tank Gauging Probe. Model: M R(2 Annular Space or Vault Sensor. Model:Z�p Piping Sump / Trench Sensor(s). Model.715- O 5__ ❑ Fill Sump Sensor(s). Model: W Mechanical Line Leak Detector. Model: Q:3 DL.-)� ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: U In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Dispenser ID: _,''j ; q Dispenser Containment Sensor(s). Shear Valve(s). Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model: V L-5 Model: ❑ Dis eraser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). elude information for every tank and dispenser at the facili 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 c mpment. F any a uipment capable of generating such reports, l have also attached a co �y of th report; (cheek all that applp): Sys t- Al, or report Technician Name (print): �J� Mme® Signature: Certification No.: License. No.: 6 Testing Company Name: AFEcR.1 n aEISE Phone No.:( g®G ) �� -S�f� Site Address: b 2nd } 6141 Z q�.� Date of Testing/Servicing: Q• /0 /617-- Page 1 of (Monitoring System Certification D. Results of Testing/Servicing 03/01