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Z O G SYSTEM O ER CA1 For Use By AU Jurisdictions Within the State ofCalifornia 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 t,&fiparate certification or report must be prgmrd )For each monitoring system control p nc by the technician who preforms the arorlc. A copy of this foam must be provided to the tank system owner/operator. The ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. AGen�Information--' v ( D�l� B idg.Noy Site Address: _ /1q4 L.,®v t Le A U& city. ZiP' - _. . Facility Contact Person: Contact Phone No-U Make/ModelofMonitoringSystc= Iy1 C / /3Aa-cO Date of Testing/SeaviciW 113 ,e7 2- B. Inventory of Equipment Tested/Certified j?6 4( y1,W v 0 01 J Cliear the. • to from to indicate rc Tank ID: G 7 Tanis ID: �F In rank carving Probe. Model: WA A / �tLr-Tans:Gauging Pwbe. Model:v/M A .� annular Space o•Vault Sensor. ModeL•.� o "t?-AnuularSp morVa*Sen= Mods: t/ v Al Piping sump/Trench Sensor(s). Mudd: VE 0 Cie N-loping sump ITmn&scnsa(s). Model: G v ® ❑ se �Modeb 4Me MecSuinp hanical Modek T �. Modeb dM UneSump Lk . — i ❑Elom oruc I;me Leak Detector. Model: ❑ - Line Leak Deteetor. Model: s%Tz&Over6u/IOgh-L&vdSeusoc: Model: Za Pw GrSd '110 Ovafi1I1 Mods O rc• j�iSa ❑Other t and model in Section Eat 2). ❑Other and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Pr+ohe. Model: ❑In Tank Gauging Pmbe. Model: ❑Annular Space or Vault Senses Model: ❑AnnularSpace or Vault Senses Model: ❑Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Seasot(s). Model- ❑Fall Sump Sensor(s). Model: ❑ Fill sump Sensor(s). Model: ❑Moi tanical Line Leak Detector. Model: ❑Mechanical I:me Leak Detector. Mode: ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Levd Senses Mode-• ❑Tek Oyu/ -yvel Smw. M ❑Other(s ui anentand model in Section Eat Pa a 2). ❑Other( ui t and model in Section E on Page 2). Dispenser ID: T Dispenser ID: 3 ❑ Dispenser Contai tSensor(s). Model: ❑ D'rsperuerContaiament s). Model: JWShear Valve(s). Shear Valve(s). D' Containment Floats Chains. Containment F1oat(s and Chains. Dispenser ID: Dispeaw ID. e ❑ DispensContainment S r(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). r ' Containment Floats)and Chains. ❑ Containment Floats and Chains. enser ID: DispenserID: ispenserContainmentSensor(s). Model ❑ DispenserContainmentSensor(s). Model- hear Valve(s). ❑ Shear Valve(s). ODises=Containment Flogt(s)and Chain(s). ❑ Dis Containment Fioat s and Chains. •If the facility contains more tanks or dispensers.copy this form. Include information for every tank and dispersa 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 pment For any anent capahle of gen ting retia reports,I have also attached a copy of the all that apply): �1 �ystem set-up Technician Name(print):_ _cu✓t.G dram r- Signature: ' Certification No: /t2 Yd 7T 3 S License.No.: 6' Testing Company Name:Tt-e_A , ��eJ er�nm�® � Phone No.:t$LVI?a_) 1. Site Address:25I� -2- ` r k :�®u A d:i,rkic„k e A QtSoS Date of Testing/Servicing: / -3 / y t— Vag-c I 1&3 \lurii(.u•i+i_��acui(_•ir-iiliGitiurl