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002195- - <br />1!B®1�T� G sY TYF](cAT®1� <br />For Use By AH Jurk&ctions Within the State of Califareria <br />Authority Cited. Chapter &7, i4eakh and 5gfety Code, chapter 16,1?ivistory 3, Tlafe 23, California Code of Regulations <br />and servicing of monitoring equipment era 'ficatiou or ort must be pre tank <br />This form must be used to docutrtent testing of this farm must be pro <br />vvlcd to the tank <br />oil each mon;.:'- •tem co tt )I Dan l by the tectiniciaa wbo pari r the, <br />form for he local agency regulatorg UST Mems within 30 <br />system ownedoperator. Tho ownerioperator nu>st submit a copy <br />days of test date. <br />A.. General info tion Bldg. No <br />2-l'�® ti <br />Facility Naroxi: `� $ City' �-P• x! <br />Site Address: Contact Phone No.; <br />Facility Contact Par= , A � Date of Testing/Sorvitiug: <br />Make/Modal of Monitoring System: <br />V <br />Tank M. <br />Q In•Taak Gwug(ng Probe <br />Q Amnnier Space or Vault; Sensor <br />Q Piping Sump tTronch,%awOT(s). . <br />Q Fill Sump Sensor(®). <br />U Mechanical Ltne Leak Detector. <br />Q Siectronie Llne Leak Detector - <br />E3 Tank Overkil /high-Lavel Sensor. <br />Tank IDt <br />Q lo -Tank Gouging Probe. <br />Q Annular Spica or Vault Sensor' <br />(3 Piping Sump t Trenah Sernsor(s), <br />Q FBI Sump Sensor(s). <br />Q Mechanical Line LeakDctector. <br />Q glactrunic Line Leak Detector. <br />CI Took OvEdillIMgh-LevelSenmr. <br />Tested/Certified <br />Model; <br />Model: - <br />Modak , <br />Modo1 _�to <br />7Ot+ <br />Modal: <br />Model: <br />Dispenser ID: ' r <br />Q e DispensContainmentSensor(s). Model: <br />C&Bhear VaiVa(3)• <br />Dispenser ID:- <br />0-0ispenserCoatainmaa Sensors}. Model: <br />"hearvalvaK _. . <br />7}>spans®riB: <br />RYDispenser Containment Sensor(s). Model: <br />M -Shear Vdve(s). . - <br />R In -Tank Gauging Probe - <br />13 Annular Spar or Vanit Sensor. <br />(3 piping Sump /Trauch Sonsar(s). <br />Q Fiu Sump s 4). <br />❑ Mechanical Lina Teak Detector <br />Q iiitrurdoLine Leak Detector, <br />Q Tank Overfill]fligh'LGvci Sensor. <br />Tank ID; <br />Q in -Tank Gauging Probe. <br />Q Annular Space or Vault Sensor <br />Q Piping Sump ITrench SensOr(0- <br />Q Fill Sump Seasor(s). <br />Q Mechanical Line Loak Detector - <br />E3 Electronic Lim I.eaklDate Sensor- <br />- Q Tank OvaHii /high- -_ <br />Dispenser aI — <br />malapcoser Cont <br />fd.Shear valve(s). <br />Model: --- <br />Model: <br />a1 drt� <br />Model: <br />Model: <br />Ivlodel:..�-•----- - <br />Modck -- <br />Model:o <br />Model: - Tw4 <br />Model:,�71------r--- <br />Model: ------- <br />Model: <br />Modek 2 <br />,ndd in Section 8 on <br />Modal• <br />Dispenser' ID: Modal: <br />El Dispenser Containment Satsor(s)- <br />U She&rrvalve(s)• <br />DisPetwer ID. Model: <br />Q Dispenser Containment Bonsor(s ), <br />Q Shear valve(s). <br />--- - _ for awry tank and disgeoser at the fact ty. <br />•If the facility �ntains mora teaks or dispensers, COPY curs Mom. 11° _ <br />C. Certitit ®tion • I certify th at the equipment identified m this document Sias;�peCted/serviced in accordance with the linfo racturers' <br />ecklists) neoessary to verity that this its, I have <br />a is <br />able of generating inch reportq C kava also <br />gnldeShtes. Attached to this Certification m int'ormation (e.g. manafaa � aq��ant cap g . <br />correct and a Plot Plan sbo-,ftg the layout of saonitarMg etaOlp'nsn rStoi re t <br />checic all t s t apply)t Q System set-up Cl Alarm�� y <br />attached a copy Of the.report; Signature: L <br />Technician Name (print): — 6-1 <br />I !s1 7' 2 <br />Certification No.: <br />� License. No.: <br />GLi Z-•_ _Phony No ' <br />Testing Company Name: �� - - 4 rGr� ��_ Date of Testing/5ervicing: <br />-Site Address:_��J -� �- ��' v <br />' 03/al <br />page 1 of 3 <br />Monitoring System Codification <br />