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MONITPRING SYSTEM CERTIFICCON For Use By All Ju*isdiction's Within the State of California Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Re dow This form must be used to document testing and servicing of monitoring equipment. A no =a *ng all= control Md by the technician who performs the work. A copy of this form must be proyided, 1W-00 tialt", system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systeW-iw ":w days of test date. A. General InformationL I Facility Name: G -e-9 —j N C, Bldg. No.:® Site Addresst —City: CA zip: Facility Contact Person: jRjcK. a_,6 -1_,4'q Contact Phone No.: Qc.9 ) 46 3 Make/Model of Monitoring System: 6/LJ34RC-0 6tn C. Date of Testing/Servicing: 1,26 2 Q B. Inventory of Equipment Tested/Certified 0 Jn-Tank Gauging Probe. Model: r"'% OZ Annular Space or Vault Sensor. Model- P,;Piping Sump / Trench Sensor(s) g0a, )COU0 Q❑Fill Sump Sensor(s). Model: �Khdcchanicsl Line Usk Detector. Model: Q Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: Q Other (specify equipment type and model inSectionE on Page 2). Tank JID: O Other tsMifj equipment type and model in Section E on 0 In -Tank Gauging Probe. Model: E3 Annular Space or Vault Sensor. Model: 5 eL%'T Iping Sump / Trench Sensor(s). Model: ja�W55.2 %.,N I e. nill Sump Sensor(s). Model: �KMechsnicsl Line UA Detector. Model: E3 l3ectronic Line Leak Detector. Model: U Tank Overfill I High -Level Sensor. Model: 20 ui I and model in Section E on Page 2). Dispenm Dispensa Containment Sensor(s). Model- fAo-).!A 2 —1 Q Shear Valve(s). ❑Dispenser Containment Float(s) and Clisin(s). �4 f Dispenser 11): p ODispenser Containment Sens6i(s). Model: fAQ2 S97,p2Wil® Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ■ *If the facility contains more tanks or dispensers, copy this form. Include Tank ID: S—"—= In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: )5l[Piping Sump / Trench Sensor(s). Model:mlmgba*�I'n Pill Sump Sensor(s). Fill Model: Mechanical Line Leak Detector. Model: �71 Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: O Other tsMifj equipment type and model in Section E on Tank ID: E3 In -Tank Gauging Prof. 7 Model - Q Annular Space or Vault Sensor. Model - 13 Piping Qu /Trench Sensor(s).KA r 0 -Ir LI Fill Sump Sensor(s). odel- 13 Mechanical Line Leak gotsct6r. Model: U Electronic U-nOsakl5etector. Model: =13 Tank /High -Level Sensor. Model: *e'fi ' p(ODWEVOquipment type and model in Section E on Pue 2). Its 71 1 7 1ilirf it i) i Containment Sensoks). Modg- ,�Viv ,"Shear Valve(s). F,.jbj,7;RWf7 7 T MM s tainment Float(s) and Chain(a). Formation for every tank and dispenser at the facility. C. Certification -I certify that the equipment Identified In this document was ins serviced In accordance with the guidelines. Attached to this Certification Is Information (eg. manufacturm' checklists) •necessary to verify that this correct and a Plot Plan showing the layout of monitoring III L For any I ment capable Of get)qating such reports, i -ham air I attached a copy of the report; (check a at apply): Mys:ern 't -up- Istory re se Technician Name (print): _JSJ� .3v,^ Signature: Certification No.: 0? V 0 License. No.: 1lq3 4reating Company Name: Acr g rz, b Phone_ No.: Site Address: qlao ®^ Date of Testing/Servicing: Page I of 3 Monitoring System Certification