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a MON.* NG SYSTEM 'i✓,➢LJll-'�T.H.dd.' V' TJONEsc By.1/l Jmis'diclions fl•ithin the,Slate of C'cthl ` .ulhori);Ciled: Clicipler 6.7, 1/eullh a d Su/elv C'orle; Chapter 16, Division 3, Tide 23, Culifr}rnia Code of Revu/u/ions. This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring systern 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 Inforenation Facility Name: NE L �AW Bldg.No.: Site Address: City: Zip: 9.5-93i Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: eGv`r —T 5.-;,Z-6<=> Date of Testing/Servicing: /a /1 B. Inventory of Equipment Tested/Certifled Check theappropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: QCT Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leal:Detector. Model: ❑ 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(s ecify e ui ment type and model in Section Eon Pa a 2). ❑ Other(specify e ui merit type and model inSection E on age 2). Tank ID: i -5 e L Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: iQ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 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-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment type and model in Section E on Page 2). ❑ Other(specify equipment ty a and model in Section n Pa a 2). Dispenser ID: j c{-2 Dispenser ID; l Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Ur Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 84 Dispenser ID: R Dispenser Containment Sensor(s). Model: 7_ E3 Dispenser Containment Sensor(s). Model: R Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). ❑ 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). *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 verity that this information is correct and a Plot Plan showing the layout of monitoring equi ment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): SY§A up---#Alarm history report Technician Name(print): W J Signature: �~ -- . Zee Certification No.: �� License.No.:� 77-1 S.Zr� 3a UT Testing Company Name: Phone No.:l _ ) 0 11.2- Site Address: 706 W CA GfSS Date of Testing/Servicing: Page I of 3 - 03/01 Monitoring System Certification D. Results of Testing/Servicing