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MONARING SYSTEM CERTIO <br />For Use By AM om Within theState qf Cal, <br />Authority Cite& Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tit e2rl,%ftfornla Code of Regulations <br />This form,mustbe used .1 document --f... .`t Iw and servicing of monitoring equipment "i 's j. <br />or t m2njUdag _m 1i)li .. ;ty ii by the e:. i + who performs 1 i"&. A copy of this form must be provided the <br />systemowner/operator. owner/operator must submit r` copy of this fbm to 4#' localagency regulating UST systemsiIt 30 <br />days of test date. <br />A. General Infer 1tation <br />FacilityNai :. s We,%: i.' <br />Site Address- 'R r r I <br />City: zip: <br />Facility Contact Pe"rson: 1Rky4-. mQvlaq <br />Contact Phone No.: <br />w <br />,. i i.' of Monitoring is: <br />• Date of Testing/Servicing. i <br />B. ofEquipment Tested► <br />Check the apprepiate boxes o Indicate equlament lumetallserviced,, <br />�� ��Tank <br />r <br />1 <br />r In-Tank Gauging Probe. Model: <br />0 Annular Space or Vault Sensor. Model: <br />ti <br />Sump / Trench Sensor(s). Model: <br />Vi <br />r r Y < ♦ r <br />r Fill is <br />1 Model.lima <br />0 Mechanical Line Leak Detector. Model: <br />Electronic Line Leak Detector. Model: <br />U Tank Overfill I ffigh-Level Sensor. Model: <br />■ , ! . r a tY t 1 t Y - i i t ' : !, J <br />,. is <br />■ Other f -ify - • Y N Section" on Pa <br />Tank I; <br />h <br />Q In-Tank Gauging Probe. Model: <br />U In-Tank Gauging Probe. Model: <br />U Annular Space or Vauft Sensor. Model: <br />E3 Annular Space or VaWt Sensor. Model: <br />Q Piping Sump / Trench Sensor(s). Model: <br />13 Piping Sump / Trench Sensor(s). Model: <br />Q Fill SumpSonsor(s). Model: <br />a Fill Sump Sensor(s). Model: <br />Q Mechanical Line Leak Detector. !, <br />■ Mechanical Line Leak Detector.Model: <br />U Electronic Line Leak Detector. Model: <br />Q Electronic Line Leak Detector. Model: <br />C1 Tank Overfill / Mth-Lovel Sensor. Model: <br />0 Tank Overfill / High-Levol Sensor. Model: <br />r itr , f ♦ ;r <br />[ <br />♦ `♦ : <br />♦!. <br />DispenserID: <br />0 Dispenser Containment%,nsor(s). Model* <br />■ Shoar Valve(s). <br />Dispenser MDispenser <br />(i; <br />0 Dispenser Containment Sensor(s). Model: <br />0 Dispenser Containment Sensor(s� Model:_ <br />U Shea tir <br />U �:f #, f ♦: i+ <br />Uf t`wI Y 1♦, i <br />Dispenser FD: <br />Dispenser i.,. <br />*. <br />0l.. f , ContainmentSensor(s).Model: <br />Dispenser <br />r Dispenser CiI !. '., Sensor(s).Model. <br />■Shear ,.. <br />r Shear Valve(s). <br />'' I of i Y. '. 3 . Y 5 t @ i ; <br />'. <br />1" ■ ♦ 1 ..Containment D.i.. and ♦ <br />thefacility containsmksor dispensers,copythis form.Includet IY :. i tfor every tankand i f:. ''♦ ' i :e r atthefacility. <br />C. i'1'thatthe r:. ! In thisdocument was inspectedherviced In accordancemanuftacturtrs <br />manufacturers'guidelines. Attached to f .. t- to that tinformation , <br />i 1 <br />correct r. :oi layout rodE 1 + ! equipmentW i L.3 n9: <br />''A/3 <br />.attachf� f Y i I - '. 1 11 if' / 1;: i!, i I� 'il 1 f, : . 1 t.. <br />Technician Nam (print): _QASCw\ 06%k <br />Signature: <br />Certification No.: <br />1.. : �...�` .. ':. <br />Pale I of 3 83ffil <br />Monitoring lCvatnm Curti tion <br />