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Nov 1,8 11 08:54a Elite V Contactors 12094616342 p.2 MONARING SYSTEM CERTI]WATION !.Juraw:cttons iliac Awhorny Cited: Chaprer 6.T. Health and SajewCode. Chapter 16. Disctaon 3. irtte-, V Californta Coen ar'Regrelariorr This form must 8e used to document testing and servicing of mtonitor: n . equipment. if more than one mailitoting system control ganef is installed at the facility, a separate cet7ifica ate, Q curt must be UMared for each monitorigg systertl rQii ojpancl by the technician who performs the m rk. A copy of this form gust be provided to the tank system owncrtoperator. The owner/operator must subx t a copy of this form to the local agency regulatiotg UST systems within 30 days of rest date. Instructions arc p: kited on the back of this page. A. General Information �' Facility Name: i fo �J . �7 �'p Bldg. No. Si- A!}5S5: 477% CET)s: ZEjU: Facility ContactPotson: _ A60',,Mev) (4 hit) Contact Phont No.: j� . } a93 - Q e i 7 Make/Model of Monitoring System �} r/t�,• � f f � � � Dna:: f Testing/Setvicing: lt' I 7 /--//— R. laventcsry of Equipment Teste&Cerfi111ed Check the appropriate boxes to ind"te specitk equipment in 0 in -Tank Gauging Probe Model: IS Annular Spsm or Vault Sensor. Madel: $ Piping Surszyamich senzor(s). 0 Fill Sump Seasm(s). Model: Q Mechanical Linc teak Detector. Model - 0 Electronic Line teak Detector. Model - 0 "lank Overfill 1High-Level Sensor. Model: 0 Dispwrer Contsiunwnt Sarsor(s). Model: 0 Shear Valve(s). Q Dispen= C Float(s) and (s). Q Odw (SIccigY !2uipR7CiiI iVftC aeW model iv Section E on puugc *) Tank ID: 0 to -Tank Gauging Probt Model: 0 Annular Spaet or Vault Sensor, Madel; C1 Piping.SumplTrench Scruor(s). rdodcl: 0 Fill Sump Serine(,;). Model: 0 Mccfranical Linc Lcak Detector. Model: Cl Electronic Line L.esk Detector. Model: Cl Tank Overfill / Higk-Level Sensor_ Model: Q Dispenser Cairsaitirnast Seeaor(S)- Modd: Q Shear Vatve(c). Q Dixpcnscr C—Minment Flow(s) alio Chain(s). 0 Other (specifY egut Ift-ME n'Pe and model in Section E on Paee 1). Tank _II)• 0 hi - 'an Gaugi' Probe.— tvtode4: O Annular Space or Vault S uor_ Model: 0 Piping SuvgyTrench Sc nt r(s). Model: Q Fill Stp Setuor(s). Model: Q Mechanical Line Leak :Cie cior. Model. Q Electronic Lime Leak l3ctt r:x. Model: C1 Tack Ovetftll1 High -Levi :Fcnsor. Model: 0 Dispouer Contairtment Se saris}. Muder: 0sitcar Valve(c). 0 Dispenser Coaraisunent Fl iris) and C wn(s). 0 Other (sEccify cq! i�xL lec and model in Section E on Page 2). Tank F£): _ (3 to -Tank Gauging Probe. Model: Q Annular.Spnceor Vault k sot_ Model: 0 Piping Sump(Trench Scrst is). Motel: O Fill Sump Sensor(s). Model: O Mechanical Line,Leak On ::or. Model. a Electronic Line Leak Deet 7r. Model: 0 Tank Overfill / High -Lr+ el : _nsor. Model - C2 Dispenser Containment ';a srr(s). Model: O Shear Vatvc(s). _.. _ ___...�.. .. .. Q Dispenser Containrnent Elc rs) and Chain(s). 0 pthcrlspeetfy equipment c n and tnodel in Sc --tion E on Page 31. C. CCFdflCat1Q11 - i certify tint the equipment identified In this document was itt p -c :d/serviced in accordance with the insnufacturers' guldellots. Attached to this Cert'lacatiac is inforntation (e.g. mut a Useturers' checklists) necessary, to verify that this information is correct a4d a Site FlAn showing the lttyottt of mazdV.-ri .11: equipment. For any equipment capable of generating such repor•tz., I have also attached a -copy of the (check alt th" a p, !j: ® System set-up report; f C1 Alarm history report. Technician Manz (print): J. .1/t, /// 'Cdt&ic. No.:8 �,_ it Testing Company Nasse: y��,/� /tom . CAU4 a3 . Patel WIN"