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N s�s�� c� T1F TH ° E �Uig D Ise Bv.tll Jurisdictions[Vithin the Stcrte of California �1rt .r Authority Cited: Chapter 67, Health and Safety Code; Chapter 16, Division 3, Title 23, California '�r�tOILS This form must be used to document testing and servicing of monitoring equipment. A separate IIOWFUT- st be prepared for each monitoring systeman _control panel by the technician who performs the work. A copy ofvided to the tank system owner/operator. The owner%operator must submit a copy of this form to the local agency regulating UST-. stems within 30 days of test date. A. General Information Facility Name: .V16-r i Oeee-, -,"0 t i.� Bldg.No.: Site Address: 7Oct cl Lj /�j f ;7,j 11, City: /`0 c��1C` �� mx�' Zip: Facility Contact Person: j /1 /� Contact Phone No.:( ) Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the ro riate boxes to indicate s ecific a ui ment inspected/serviced: Tank ID: T ank � In-Tank Gauging Probe. Model: ing Probe. Model: _ IdAnnular Space or Vault Sensor. Model: Ll or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model Z r Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model sor(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(specify e ui meat ty a and model in Section E on Pa a 2).EEEE]EEEEr ecify a uipment ty e and model in Section E on Page 2). Tank ID: I- /t//fA ❑ In-Tank Gauging Probe. Model: Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: p 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: r- Co,f a uipment type and model in Section E on Page 2). ❑ Other(s ecify e ui ment type and model in Section E on Pa e 2). 'Z Dispenser ID: I ontainment Sensor(s). Model• 42 E ❑ Dispenser Containment Sensor(s). Model: (s). ❑ Shear Valve(s). ntainment Float(s)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). El Shear Valve(s). E3Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: M4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispense Containment Float(s)and Chain(s). *lfthe facility contains more tanks or dispensers,copy this fonn. include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in tha oeument was i i spected/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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that at)plp): E1ystetnAt-up 3-Alarm history report Technician Name(print): r1 Vl'1Z ;'r kip kf Signature: Certification No.: ,' 7 '� 52 `73 UT License.No.:1)_TL -�" ��- Testing Company Name: --=1TC2rbA t �p- Phone No.:( 20 Site Address: Date of Testing/Servicing: rd / G)/ Page i of3 03/lil 19'IoniQoo-L,System C'ca tiresation D. Remufts t�f v4 alar/ 6 v Gt al��;