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"60AMON &A) l--or• (Ise Bl.All Ir(v-isdreliu;.' irr7he.SYulc'ofC(-1fif)07h1 dhol-k C'ile(l: Chap/er•6.7, llect/lh cmd S(f ) ('o(1e; CIngVej 16 Divi, oL. QI .f ule 23, Ccr/rI& i)II C'0&1 U�l. 1 f .,t(lcrlion,t This form must be used to document testing and servicing of monitoring equi separate certification or report must be prepared for each monitoringsystem control 13anel by the technici { t A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit �j p � the loca�gency regulating UST systems within 30 days of test date. A. General Information Facility Name: $WO CLWr � By { Bldg.No.: Site Address:J.47 f=, i=R-yaaP aa City: Xc)P Zi p:-15 55 � Facility Contact Person: --IML Contact Phone No.:( ) _ W4, Make/Model of Monitoring System:—&EbEg— Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: c t:T Tank ID: �j In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: / Annular Space or Vault Sensor. Model: xCJ Fill nnular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: `LG} iping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Sump Sensor(s). Model: J( Mechanical Line Leal:Detector. Mode1:57P-MI,® Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify e uipment type and model in Section E on Page 2)• ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: C'�G Tank ID: In-Tank Gauging Probe. Model: �} / ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Zt��i ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:26f -�'/O ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. . Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify a ui ment t e and model in Section E on Page 2). ❑ Other(s eci a ui rnent ty a and model in Section E on Pae 2). Dispenser ID: l°� Z Dispenser ID; —T 4 Dispenser Containment Sensor(s). Model: Dispenser Contaimnent Sensor(s). Model: f Shear Valve(s). Shear Valve(s). LIDispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: `� Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment SensorE) _ del: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(sain(s). Dispenser ID: `� Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensordel:Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Contaimnent Float(s)and Chain(s). ❑ Dis?enser Containment FloaP{sin{s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser 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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that app(p): RSy et- R—U.Alarm history report Technician Name(print): 'Z4/yp- /yir oLa Signature: Certification No.: /%93 �5 4 93a "U T' License.No.: /��--� .� Testing Company Name: yC Phone Nojaoo)'� Site Address: i q7 C t9 12 o Date of Testing/Servicing: f Z / / . � Monitoring System Certification Page 1 of 3 03/01 A Results of Testinb/,Servicing