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K MOP40RING SYSTEM CSE+ R IA'TT ON !-or l'se 81'.1// Iru•isdic•liuus 1171/1hi the Slate of'C'alifurnht Aulliorihv Cilecl: C'hapler 6. 7, Health Coe/e, C'lxrpter 16, Dirisiorr 3, Tillc 23, Califbrnia Coele of Re1�1,ulaliorr, This form must be used to document testing and servicing of monitoril iOf e certification r. tePoI tAlitist be ,, prepared for each monitoring system control panel by the technician who perr A of this form nxist,be io cied p to the tank system owner/operator. The owner/operator must submit a copy of I i orm k the local agency regu11111 g UST systems within 30 days oWest date. 2008 A. General Information ENVIRONMENT HEALTH Facility Name: / Bldg. No.: Site Address: //03 $'. /t/J�f/�/ S, City: AA(7r Zip: -'T75537- Facility 553Facility Contact Person: 46f21t✓ Contact Phone No.: ( 209 ) $ZS- 01 -� make/Model of Monitoring System: (-i�-�-3 ® Date of Testing/Servicing: y /22/dS B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecitic equipment inspected/serviced- ID: �i� ®G'f Tank ID: -Tank Gauging Probe. Model: 4 t 0 In -Tank Gauging Probe. Model: nnular Space or Vault Sensor- Model: t J9 Annular Space or Vault Sensor. Model: p Iff ping Sump /Trench Sensor(s). Model: O $,Piping Sump / Trench Sensor(s). Model: 20� ll Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: eehan ;cal Line Leak Detector. Model ❑ Mechanical Line Leak Detector. Model: ectronic Line Leak Detector. Model: /ii -D A Electronic Line Leak Detector. Model: P nk Overfill / High -Level Sensor. FMechanical Model: ❑ Tank Overfill / High -Level Sensor. Model: her (specify equipment type and model in Section E on Pa =e 2). ❑ Other (specify. equipment t pe and model in Section E on Pae 2). ID: Tank ID: Tank Gauging Probe. Model: f ❑ In -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ing Sump / Trench Sensor(s). Model: O ❑ Piping Sump / Trench Sensor(s). Model: l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model•chanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: A Electronic Line Leak Detector. Model: P44-0 -Q ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty a and model in Section E on Page 2). ❑ Other (s eci a ui ment tye and model i Section E on Pae 2). Dispenser ID: B"a Z Dispenser ID; B) Dispenser Containment Sensor(s). Model: goo_ A Dispenser Containment Sensor(s). Model: Zp $ 1-d. Shear Valve(s). iLShear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3.1-'f Dispenser ID: 9 -4--10 A Dispenser Containment Sensor(s). Model: $ 8. Dispenser Containment Sensor(s). Model: 20$ liff Shear Valve(s). 0- Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5$4o Dispenser ID: l i y- l Z - $I Dispenser Containment Sensor(s). Model: 2" a- Dispenser Containment Sensor(s). Model: -0!6 0 Shear Valve(s). W -Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). j ❑ 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 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 apply): System set- �Alal m history report Technician Name (print): ��FIaV�' �V a-0 Signature:_ Certification No.: J/ License. No.: a 2Q -- a-7 Testing Company Name:-LT�'nroii _ � sr Phone No.:(,Q6 I_)'%/g/ Site Address: l f63 $. 'A40q"W-r-r Date of Testing/Servicing: 2-4-P08 Page 1 of Monitoring System Certification D. Results of Testing/Servicing 03/01