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MON#ORING SYSTEM CERTIRCATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be Drepared for each monitoring system 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 Information Facility Name: W t 1- '50^3 u%e�y C-4i-z�uxeyJ Bldg. No.: Site Address: 4K-2-7 �L Lal t L ko rJ W IQ -s City: S' c /<7S d Zip: 4 !02(Og- Facility Contact Person: �— Contact Phone No.: (__) Make/Model of Monitoring System Vel 4PZ T tZ� S- -6 G -b Date of Testing/Servicing: / C / g�S B. Inventory of Equipment Teste(UCertifled Check the appropriate boxes to Indicate spectik equipment ced: Tag*ID: Tank ED. 9 Tank: Gauging Probe. Model: _�t.a ❑ IntTank Gauging Probe.,Model: .,6mulai- Space or Vault Sensor. Model: '? - `, tl - _ _ ❑ Annntar Space or Vault Sensor. Model: E PiW g Sump 1 Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: �ill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Iechanicai Line Lzak Detector. Model: STP—A4 c -D Cl Mechanical Lane Leak Detector. Nlo&h ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill f High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ifvui ment t and model in Section E on Page 2). ❑ Other (specify equipment and model in Section E on Pm 2). Tank M. ®"Tank Gauging Probe. Model: „.�� ❑ In -Tank Gauging Probe. Model: Aaaular Space or Vault Sensor. Model: `7 Zy3f-b _yzs? ® Annular Space or Vault Sensor. Viodel: 2T*ng Sump / Trench Sensor(s). Model: '7�p4< SCD_ ❑ Piping Sump / Trench Sensor(s), Model: 2� tr f*Sump Seasor(s). Model o _ , ❑ Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: ❑ Mechanical Lane Leak Detector. Modei: Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (2ecifl Sguipment pr and model in Section E on PaLe 2). Cl Other (specju!pment(spec' type and model in Section E on Pa 2). /Dis '� a 2' �' - �F:n IDser Containment Sensors}. Model: ✓ ' Dispenser Contaitarut Sensors}. Model:C i:z 1'Z--C?� Vatve(s). Q -Shear Valve(s). Bic ser Containment Float(s) and Chain(s). ® DiUmser Containment Float(s) and Chain(s). er ID: DFp DispenserID: enser Containment Se'nsor(s). Model: "3�'� c' Z t Z ` GG( ❑ Dispenser Containment Sensor(s). Model: r Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Blsumser ID: Dispenser, ID: Q'�penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ shear`J;S ❑Dispenser Containment Floats) 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 dais document was inspeeted/ser-vieed in aceor-danee 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 eqtn9juent. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that appty): System set-up EaAftirm history report Technician Name (print): _ 4Z -v <N ,-4-t /�� 43 Signature: a Certification No.: License. No.: TO 5� 100 Testing Company Name: 6A4_P146161aAJ f L)k- A-E2l, hone No.:(� ) `gc° Site Address: `f-17 N• (o: L Sad (.r)• r S72f�1�� .¢t Date of Testing/Servicing: q-O^zq MonitoringiJ ll (C D Monitoring System Certification Page I of 3 �C E ®3,01 r ' AUG 2 9 2003 ENVIRORMENT HEALTH PERMIT/SERVICES