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F By AHJurisdictions Within the State ofal4a Fi C Ti . Cal aWornza Code ofRegulaftons Authority4CUed. Chapter 6.7,HeWand Safety Cha Code, pter 16,Division 3, be separamust phis form must be used to document testing and servicing Of 1110111tDring equipment A to certification or reDort nreoaarms the work- A copy of this form must be provided to red f I bx1mician perf M each monitoring fflslemSMPLOl by the who systems the tudc system owner/operator. The owner/ for must submit a copy of this form to the local agency regulating UST within 30 days of test date. A. General Information Facility Name: (o,' Bldg.No.- Site Address: city; lvx-'l Cx Zip: 1� Facility Contact Person. Contact Phone No.:00? 11232,2,9.�7 Date of Testing/Servicing: 0' Make/Model of Monitoring System: B. inventory of Equipment es Ce Check the appropriate boxes to indicate s1pecine equipment Inspectodkerviced: ED: T�A� T2nk M: k—G; - Model: A I El ID-Tank Gauging Probe. Model: 41,4 u pular S 0 alar Space or Vault Sensor. Model: �nugl Model; Ef Model: 2_01 Piping S 1P1 ump Sump Trench Model: j/,Z P S, S Trench Sensor(s). �'Su U Fill Sump Sensor(s). Model: C1 Sump Sensor(s). Model: _T�T /T/ FMechamcal Line Leak Detector. Model: 'eZ"_ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: E3 Electronic Line Leak Detector. Model: lb-Tank Overfill/High or. U-Tank Overfill/H%1--teve Tffi§or M o d e 1: Page 13 Other ify equipment type and model in Section B on Pap 2)_ 13 Other(T!*SuE�DW and model in Section E on 2). Tank ID: Tank 11): • in Tank Gauging Probe. Model: 13 in Tank Gauging Probe Model: • Annular Space or Vault Sensor. Model: (3 Annular Space or Vault Sensor. Model: • Piping Sump I 7hmch Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Mode): • Fill Sump Sensor(s). ' Model- C1 Pill Sump Sensor(s). Model: • Mechanical Line Leak Detector * Model: Ll Mechanical Line Leak Detector. Model: • Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: • Tank Overfill I High-Levet Sensor. Model: U Tank Overfill/high-Level Sensor. Model: • Other(specify equipment typeand model in Section E on Pap 2). E3 Other(specifyaqui tfte and model in Section E on Page V serCon ID — Diapi 277 tainment Sp6sor(s). Model: ❑ ser Cnatai"M qensorK Model: I ......ant V Va at Valve(s). a 'e(s). MD*mw Conftinment Floats)an (s). a "'arCon simment Floats)and Chain(s). D ID: Dispenser 1D. 0 Con a Model: 0 Dispenser Containment Sensor(s). Model: S Shear Valve(s). ispenser Containment Float(s)and Cham(s) 0 Dispenser Con Floags)and Chain(s). ..Dispenser ID. Dispensw ED: 13 Dispenser Containment Sensor(s). Model: (3 Con tafimentlgensor(s). Model- 0 Shear Valve(s) U Shear Valve(s). QDispenser Containment Float(s)and Chain(s). (3 Dispenser Containment V2Vj(s and Chain(s). -If the facility contains mom tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. CL tion - I -certify that the, equipment Ids tifled In this document was Inspectefterviced in accordance with the manufacturers'guidelines. Attached to this Certification is Information(ag manufacturew cheddists)necessary to va*that this information Is correct and a Plot Plata showing the layout of monitoring p;1!; Spt%,,-For"W4quipmen able of generating such e MTor%I have also attached a copy of the report;(ekeek&F1 that ap, - to -up history report Technician Name(print):-Tom Corcoran Signature: �77 z-� /- -- — Certification No.:_ 00 7 S 3 R License.No.: 0 -j—-/6 2- Testing Company Name:Triangle Environmental,Inc. Phone No.:(818)840 7020 61 Site Address: Date of Testing/Servicing: Pap I of 3 03/01