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ON' 1�1G SYSTEMCE TIFI TI N r F e By All Juris•diclions I4%71hin /he Slale of Cali cr Arrlhorvty C'iled: Chapter 6.7, Hear, r acrd Sgfely Cocle; Chapter !G, Division 3, Till, 23, California Code of Regalcrlion,r This form must be used to document testing and servicing of monitoring equipment. A separate certific ' ice. �r8, t'1 f t prepared for each monitorings stem control �y pane( by the technician who performs the work. A copy of this ri t�1•p �{ � �l the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems vVRAin 30 days of test date. t=ii T' 4 2007 A. General Infor nation (°� s Facility Name: _ alk 101)p Site Address: Facility Contact Person: Contact Phone No.: Zip: Make/Model of Monitoring System:7" - l Date of Testing/Servicing: / / 0'7 S. Inventory of Equipment Tested/Certified'ga 0�� Check thea ro riate boxes to indicates ecifc a ui ment ins ected/service ID: ❑ In -Tank Gauging Probe. Model: 1Tank ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: A15 •13 /* 13 Fill Sump Sensor(s). _ Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecif equipment ty a and model in Section E on PaLe 2). Tank ID- ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 '1/i __121 ❑ Dispenser Containment Sensor(s). Model: 'Al 01 ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID:j„ ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Model: Model: Tank ID: Pa) / -�o t ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. 0 Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and i Model: W 4�1, 4L, Model: 3 Model: Model: Model: Model: Model: iodel in Section Eon Paee 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci equipment t e and model in Section E on Pa a 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Lf D,1- ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: `;?_q_ - <;�" ❑ Dispenser Containment Sensor(s). Model: �(� — ❑ Shear Valve(s). ❑ Dispense Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include informationfor eveerry tank and dispenser at the facility.Lr&�- C. Certification - I certify that the equipment identified thie1,(. wi ns cted/seine /inacwith the manufacturers' guidelines. Attached to this Certification is information (e.gmanuficturers' 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 attacI ed a copy ortne rep rt; (check aflMal apply): ❑ Syste n set-tt f ;® Xharfn it storya•eport Technician Name (print): /% ?,r� Signature:_� Certification No.: License. No.: Testing Company Name: f p $ is `g - Phone No.:( 10 /f -7 Site Address: to �7 v,) Date of Testing/Servicing: Page 1 of 3_' Monitoring System Certification D. Results of Testing/Servicing 03/01