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Rrom.. - is MON#ORING SYSTEM CERTIFICATION AUG 2 2008 For U.ve BV, -111 316'(Iicliolls Wilhin the .Slcrle of calilbrniu Aillhor'ily C'iled: C'hapler 6.7, ffeal/h and Safely C'o&,, (/leafler /6, Division 3, Tile 23, Cali orn This form must be used to document testin" and servicing�equip ERrii's of monitoring ment. A separate cern kation or report mist b }arc pared for each moniforinystem control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. Theowner/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: (; i;.,,JY 0, (7 ( Bldg. No.: Site Address: z = i1J CA ► 1 City: - C i g 1- Zip: Facility Contact Person: f, </ ;r , Contact Phone No.: Z 0,1 Q -z Make/Model of Monitoring System: f (_5 - Cay) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecif a eouinment Tank ID: i )� E Tank ID: }[s }.� hi -Tank Gauging Probe. Model: M 4 Amwlar Space or Vault Sensor. L( In -Tank Gauging Probe. Model:( ) ( , Model:(7 Uf Piping Sump / Trench Sensor(s). Model: X.Annular Space or Vault Sensor. Model: LJ Fill Sump Sensor(s). Model: Piping Sump / Trench Sensor(s). Model:? ❑ Fill Sump Sensor(s). W -Mechanical Line Leak Detector. Model: Z -D -�C:)CC> ❑ Model: 5( Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other (s ecify equi ment ty a and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e ui tyee Tank ID: ment and model in Section E on Pa e 2). ❑ In -Tank Gauging Probe. Model- ❑ Annular pace or Vault Sensor. Model• Tanks ❑ In -Tank ugingProbe• Model: _ ❑ Piping Sump / Trench,Sensor(s). ModeC ❑ Annuhr Space or-Vau. Sensor. Model: P ❑ Piping Sum /Trench Sens P g P r(s)� ❑ Fill Sump Sensor(s).dVlodel: aadt : ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detec r. Mildell Ll Electronic Line Leak -Detector. Model• ❑ Mechanical Line Leak•Detector. Model:�� -A.. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Liner ak Detector. Model- ❑ Tank Overfill / High Sensor. ❑ Other (specify equipment type and model in Section E on Page'2). -Level Model: ❑ Other (s ecify a ui ment t e and model in Section E on Pa c'2):-, Dispenser ID: Dispenser Containment Sensor(s). Model: Z®ej Dispenser ID: (_Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Ll Shear Valve(s). ZC}a ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dis(tenser Containment Sensor(s). Model: ❑ Shear Valve s)- Dispenser ID: ❑"Disp nser Containment Sensor(s). Model: ❑ She ar a L3Dis enser Containment h3at(sj a d-lalfam(s). ❑ Dispenser Conti Inapt Pfn fftel —A ! � Dispenser ID:_ • Dispenser ID: ElDispenser Cont rnnient Sensor(s). Model: ❑ Dispenser Cha nment Sensor(s). ❑ Shear Vallee sj ❑She v1'e(s). ❑Dis enser Containment Float(s) and Chain(s)• `° ❑ as enser 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 equipmet. or any equipment, capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑N�nt ❑ Alarm history reportTechnician Name (print): Felix Ramirez Signature: Certification No.: 4 - 7 6 , License. N8-1740 ICC# 5273 34-U .Testing Company Name: /-,\f ?_ °a Phone No.:(ZC>-) Site Address: q1 6, r _q i 1 D �j Monitoring System Certification Page I of 3 A Results of Testing/Servicing ate of Testing/Servicing:/% Q3/O1