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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 app/t): IR Sy ( Alarm history report Technician Name (print): =40NUe r',Zmo Signature: Certification No.: 893 License. No.: 6 U W B24 33 .7 ~ U 7- Testing Company Name: - �4m _ Es r Phone No.:� � �%'Si</ - 0&.z Site Address: _ +7-" rj. 4 UA,, - Date of Testing/Servicing: / S 16 Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03101 MON*RING SYSTEM CERTI 'I 'TI For Use By AII,Inr•rsdiclions 1171hin the Slave of C'crlifbrnio Arvhorih� Cited: Chapter 6. 7, Fleallh and Sc?P/v Code,- C'halver 16, DiFisiorr 3, Tile 23, Cal forma Code of Regyida/ions This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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 cop this form to the local agency regulating UST systems within 30 days of test date. A. General Informat'on ,, ll Facility Name: f W /moi % Bldg. No.: Site Address: 6'17 A) d 44e/ City: 5 A.V t �n Zip: lrZZ) 2 - Facility Contact Person: -PAS i d Contact Phone No.: {��) !l� / 15,71 Make/Model of Monitoring System: yp_ TQI ? 5-L Date of Testing/Servicing: / S—/ 7 B. Inventory of Equipment Tested/Certified Check the approeriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: Tank ID: In -Tank Gauging Probe. Model: /ILv" i �siln-Tank Gauging Probe. Model: / Annular Space or Vault Sensor. Model: t/ ? It Annular Space or Vault Sensor. Model: Y7 O Piping Sump / Trench Sensor(s). Model: 2y,F U( Piping Sump / Trench Sensor(s). Model: Zd� ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: C c o kElectronic Line Leak Detector. Model: ftt ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecif equipment type and model in Section E on Pa e 2). EIOther (specify equipment t e and model in Section E on Pa a 2). Tank ID: b 1 ,�_ Tank ID:�) Z In -Tank Gauging Probe. Model: i In -Tank Gauging Probe. Model: �,,er G Annular Space or Vault Sensor. Model: V20 Annular Space or Vault Sensor. Model: � ZD gL Piping Sump / Trench Sensor(s). Model: & Piping Sump / Trench Sensor(s). Model: ' ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ''Electronic Line Leak Detector. Model: (I'[[ 14lectronic Line Leak Detector. Model: P&I09� ❑ Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: ❑ Other (specia a ui ment ty a and model in Section E on Pa a 2). ❑ Other (s eci a ui ment tXee and model in Section E on Pae 2). Dispenser ID: --7 Dispenser ID; z -� Dispenser Containment Sensor(s). Mode(: FI/7fe t10 • 00 1 PrDispenser Containment Sensor(s). Mode(: n J Shear Valve(s). Rf Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). erID: - 7 Dispenser ID: -� fpe Dispenser Containment Sensor(s). Model ®D t Dispenser Containment Sensor(s). Model: py I Shear Valve0. /Zl Shear Valve(s). Dis enser Containment Float(s) and Chain(s). LJDispenser Containment Float(s) and Chain(s). Dispenser ID: // gDispenser Containment Sensor(s). Model: bo 1 Dispenser ID: / 0 ' 'L A Dispenser Containment Sensor(s). Mode(: ) Rf Shear Valve(s). �, ,el Shear Valve(s). IN ❑Dis enser Containment Float(s) and Chain(s). ❑Dis 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that app/t): IR Sy ( Alarm history report Technician Name (print): =40NUe r',Zmo Signature: Certification No.: 893 License. No.: 6 U W B24 33 .7 ~ U 7- Testing Company Name: - �4m _ Es r Phone No.:� � �%'Si</ - 0&.z Site Address: _ +7-" rj. 4 UA,, - Date of Testing/Servicing: / S 16 Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03101