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01/02/1995 03:27 2097546722 %ALAVERAS EM/ HEALTH Mbt- ni MONITMUNG SYSTEM CERTIFY TION [ ED fc,- t.!s�, - .tuthority Cited: Chapter 6.7. Health and Sojety Code. Chaprer 16. Division 3. 7?tle 23. California Cady nr'Regularifty 0 5 2004 This form must be used to document testing and servicing of monitoring equipment. If moM,{ti iii' NT HEALTH monitoring system control panel is installed at the facility, a to certificatio n mut bc kiAMERVICES each monitorin(t systrm cotZol_pancl by the techni6an 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 '!Deal agency reg+tlatirtg UST systems Within 30 days of test date. Instructions are printed on the hack of this page. A. GenerglInfot tion yy_ l FFacilityme Na: ri � � / Bldg. -�— C;r.. Address• Facility Make/Model of Monitoring System B. Inventory of Equipment Teste&Certfled ilk No.: City- (i !� // '' ! Zip- ff _ contact Phone No.: c <r 2ID L- X Date of Testing/Serviciog: / tins serviced: (,"heck tae appropnatt oozes to tntttcaac-. Tagk ID: Taal U3 ®°ln- ask Gruging Probe. Model: Model: 3 Ef to-Tank Gauging Probe. Q-Atmulr Space of Vauli Sensor. Modcl: (Anular Space or Vault Sensor- Model: Wpipmg Sumprrrrneh sensor(s). Model: 7� r-/ 3��b b8 ePiping Sump(Trench Sensor(s). Model. O Fill sump 5e%sor(s)- Linc Leak detector. Model:-C�_ Model: ra mw-y� ❑ Fill Sump Senwr(s)- 9"Meehanicat Line Leak Detector. Model: Model: t 171) Q40eehanical 0 Elecnonie Line Leak Detector. Model- 0 Electronic Line Leak Detector- Settlor. Model: Model: %ask Overfill / High -Level Sensor. Model: C) -FC5i 0 T-ak Overfill t High -Level Sensor(S). Model: L j 0 (- 2-d "(GL r Contn `,scs:os(y). 9�1)ispensctanntre Model: �� 4 CC 1J ✓�.L CI Disl'�enterContatnment ¢Shear valve(&). O Shear Valve(s), 04ispensu Contairunent Floatts) and Chaim(&). 0 oispeneer Containment Float(s) and Cham(s). 0 Other(spccsuiMent type and model in Section E on Px c Z). Q other (sEEcify equipment t and mode) in Scction E on Paec 2). Tank iD: Tank ID: 1 i t`z d ❑ In -Tank Gauging Probe. Model: % 3` L ` 0 In -Tank Gauging Probe Model: �i `17 3 � `�_L� L_ C/ 3 J �/D / 0 Anna(u Spam a v cult Sensor. 0 Piping Stimp(Trench Sensor(s)- Model- Model: Y e� O - -'06 O Annular Space or vault Sensor. O Piping Smnpffrench Sensor(&). Model: _ 7 Model 7Cd y:3 6 C) " D CY Q Fill Sump Sensor(O. D Mechanical Line Leak Detector. Model0 Modcl: C d TQC' — Fill Sump Semor(s). O Mechanical Line Leak Detector- Model: ^ Model: 0 Electronic Lute Leak Detector. 0 Tank Overfill / High -Level Sensor- Model: Model: �_ -7 30 - i 0 Electronic Linc Leak Detector. 0 Tank Overfill / High -Level Senwr_ Model: Model: 7 - /S 4 0 Dispenser Containinew Sensor(S). Model- , �i J 'r'r x rf.. r 9 0 Dispenser Containment Sensor(s). Model: ?o a C& 0 sheu Valve(&)- 0 Shm Valve(s)- 0 Dispenser Contaimncot Flost(s) utd Chain(s). O Dispenser Containment Flou(s) and Chain(s). O Other (Specify equipment type and model in Section E on Page 2). D Other equipment and model in Section E on Pa c 2). C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guldelitses. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that ttrls information is correct attd a Site Plan showing the layout of monitoring equipment. For any equipment capable of `eneratiug such reports, I have also attached a copy of the (check all that apply): O Syste set-up report; a history report. Technician Name (print): l CertJ-Linc. No.: Signature: /v/�J/ Testing Company Name: �? 1� Phone No.: �<-e CALM -01 Page 1--....� — pot 4ir Fax We 7671 QG peg" T. - craw /1 Q r S