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Oct 17 12 08:36a Elite IV Contactors 12094616342 p.2 <br />Apliendix V1 <br />(Copies of Monitoring System Certification form and UST Monitoring Plot Plan availebl :atAM://www.water!loar s:_ca-cov.) <br />MONITORING SYSTEM CE TIFICK IO <br />For Use By AffJudssdret/aas Within Nae State ofCallfonda <br />Aidthroffty Efted. Chapter 6.7, Health and Safety Code; Chapter 16, Divisk o 37 Title 23; Callibmia Code of <br />Regulations <br />This form must be used to document testing and servicttag of monitoring equipment A separate c rNiration orrept�t•must be prepared for <br />-each monitoring system control panel by -the technician who performs the work.. A copy of thi: f :7n must t •provided to the tank system <br />ownWaperatoc The ownedoperator must submit a copy of this form to the loaf agency regul6lin l t ;Tsystems within 30days of Last date. <br />A. General Information gyp, '� [[ � _ g, � , �g t <br />Facility,. Name: ttJCi fte"L c l I ° i 1 + ) tfi��t ( t _ it. No,: <br />Site Address 19�t E, 1 G ,. r e. _ _ P• <br />F lity contant Person:'_ i ' hi Conrad Phone No.: <br />Mika Madel of Mond 8v" tem: <br />Data of Testlnw� "Ing.. <br />B. .Inventorypf•Equiprment TestadlCeitlfred <br />Check the s ro 'ete:'boxes to Indicate specific equipmenti ectedfserviced: <br />Terik IA: ' .. .- <br />s. C _ Tank• IV. <br />L .Irl Tank Gauging Probe. hAoc lr D An -Tank Gauging Probe. Model: - <br />t= .•AnnularSpace or VaultSensor. Model: • D Anrttrlar-Space'or Vault Sen>o •Model: " <br />C <br />piping -Sump /Trench Sensor(s}. Model: ; ❑ PoindSump/ TrencchSemi w( Model:. <br />C . Fill'Sump-Sensor(s� Model 17 FI11 swrpSensogs). - Model: <br />Ic Medtanicaitine teak Detector. Model: i.0 Mechanical tine Leak Detecto Model:.. <br />X Electronic brie Leak Detector. Model: ' . D Electronic lira teak Detect: r. Model:o . <br />C Tank Overfill t ugh -Level Sensor. Mbdel: 0- Tank Overrill:l Him -level Sr• m r. Model: <br />L..x7tl;er- ant. and model in Santiwa E an P 0. Other LaRecify a u' menti e. ti modef in Section Eon Page 2). <br />Tank m I Tank ID: <br />'r. In -Tank Gauging Probe. Model: f7 In -Tank Gauging Probe. Madel: . <br />Arutar emacs or Vatt Sensor. model: u ArinuJar $page or Vault Serie zr Model: <br />C Pi3uig''5timp/?r�nch'Seiasbr(s) Model: d Piping �Caiiiji.l.i`ietsch 5emsa (s Modol: " <br />C: -F111Sump Sensoi(s). • . Model: O Fi11•Sump Sensar{s}_ Model: . <br />r_ Mahapicw Lim teak Detector. Model: 0 Mechanical Una Leak Detemor. Model: <br />C ~tec#roploLineLeakcefaclor. D .Elewanic•LineLeak 'Detector. - <br />. 7 k erfiII f,tWightLevet uairsor.. Madel: D _Tactic. ; Hi"vel.Sw sc Model., : <br />[:.0 nd Woe and model in Section E on Pae . 11 011ier mnimnRnt twns a i MoCie in Section E on Paae 2 <br />speiaseTiD`e`" . _ .. IDispeijset'ttati <br />L Di 6ser ContahgmntSensor(s). Model: uDispenser Containment Sensor(. Model: <br />C . Sbear.VaNe(s)_ 0 Shear vatve(s}." <br />C Di rimer Contairttment Fla arui chaka s . 0 Di Conhainmend Floe' and Cthain(s . <br />' pispen�erlD: 1N send:' <br />Di "" ".: ;Consainment$erisbr(4). Model: II miser ntainmerASensti:r(: Model: - <br />G shear lialue(s� D ShearValde(s). <br />C :.t3isp®m'4_i-'whtainment.0o s andChai 2 s . [7 Dl Containment Float : L s l Frain <br />DispetlrlD: Dispenser 10- <br />C Dispenior Containment Seresor(s). Model: Q Dii nser Containment Ser�c (s Model: <br />L_ _She <br />alve(s) U - Sh®ar VaNe(sj.: '> <br />..ntatame Xloas Chain <br />tf tBe _kat lily ooritalns more faults c sspprsers,'copy this form. Include inforg tion for, Averytank_and disperser -t,t : hrjllty_ <br />r CertPNc�ti�b_L.ceixlfy�lat�t�uipinec>f_rr�:ntlffarLi211iis_dncumeaLwas frispectedlse[vlced�Fr r i�tdaiace...with-2fiedrttanufaclurets°-:----.— <br />gUide(cnes, Affached3a. (ids oeracatjon is lnformatiofa .(e g marnrfactir etocktxrta) riacessary tc i rfty,11:0t.1bis Intimation is =rract <br />and s Plot Ptah shouping tt►e istyrout of-monita fig egttfpment For any metal capable of gereratical itch reprts, f (have also attached a <br />_-;F : n� ". Fstery _ – - - <br />7ecfatitianName (prinU „ Signature: <br />Certification No.: No.: <br />:TYPlame:-t �� tint Phone,;No:iL.0 e..�. <br />T < Cofri a " Address: 1L1 i� %+:1111 �1 (�,�lllL i i "t, ('( DatedTesilnillf ra _-- <br />esfmg-. 13. fcin*: 1 l d <br />h@onitoiing System Certification Page 1 of 4 1207 ' <br />1 2/21%47 <br />- e t <br />+ e f <br />6 E > t <br />