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JAN-1-2002 04:18P FROM: TO:12094683433 P:2/8 MONIT RINGSYSTEM C:E TIF1 TION For Else lav.111,4ur1_vctictions Within the State of t'•olifornia iluthority Cited,Chapter 6.7,health acrd,Safes;:Code;Chapter 16•Division 3, Titte 23, California Code of Regulations This form mast be used to document testing and :rvicing of monitoring equipment, A. setaarate certification, or report must be prepared for each mattitorin�system control Hanel 'rad:(lie technician who perforins the work. A copy of tl 's form must be provided to the tank system owner/operator. The owner/oper;;1 >r must submit a copy of this form to the local agency r gulating UST systems within 30 days of test date. A. General Information Facility Name: ec1t&, 4- 7. ... -_ Bldg.No.:__ Site Address: /Sae N '"Aeee -FOAJ ; Z11 City: 7_,ip; 5'S3Gty.m Facility Contact Person: Rle?,4 9/a„ Contact Phone No.: Make/Model of Monitoring System: 967) �'�e�, �r mate of Tcsting/Servicing: B. Inventory of Equipment Tested/CertifiOd Chest:tice a p eagle hcuccs(oh aue ui scent� Ccxuse rveCed: Tank Id: / o.Guv &r,+&.yAl boese?L- Tank l.D:7 ,r� easy [3�tco�►/ 1 Sg: • In-Tank Gauging Prole. Model: a in-Tank trangin€Probe. Model: _ _ 11 Annular Space or Vault Seer. Model: R L qo_�Gl z- 111 Aiutular'Space or Vault Sensor. Model R4"*g,!s ■ Piping'Sump I Trench Sc•n.sor(a). Model: 8A: YAZ:'A)1-5 IN Piping Sump/Trench Scnsor(s). Model: ❑ !rill Sump Sensor(s). Model: tri Fill Sump Sensor(s). Madel: Ii Mechanical Luk Leak Pctcclor. Model! / ' Fes',j►- ®Mechanical Line Leak De=10r, Mwel: Y& rxi 5 V _ ❑ Electronic Line Le,6k Detector. Model: ❑ Elc chwdc Lint Leak Detector. Model:_ ■•Tank Overfill/high-Level Sensor. Model:XGI � e�c.rs- ll Tank Overfill/lligh-Level Sensor. Model: ❑ Othca 5 i ui ment tv Pe and model in SeeKiort 1:or. Pe 2 . ❑ Olhea ci ui tent and model in Section F on P 2). Tank ID: 03-2-o ancj 6-AMA611 d e�SC-Z� _._^ Tank 1D: ® In-Tank Craaging Aro . Model: O In-Tank Gauk�ing Prole;, Model:T-..,. 41 Antlular Space or Vault Sensor. Model:� _ t_qZ_ if1 Atlnular Spare 2r Vault S tsor. Model: aC `/m r Piping Sump I Trench Scnsor(s). Model: 1ZE cv_:ler ® Piping Sump I Trench Se nwr(s). Model: AL 4� �1�I 5 ❑ rill Sump Sensor(s). Model: _-- ® fill:lump Sensor(s). Model: - ® Mechanical Lint Leal,Detector. Model: f -Ac l 1s Mechanical Litre Leak Detector. Model: uL2 � ® Rlc-ctronic Line i. ik Detector. Model: ❑ Ric utronic Linc Leak Detector. Modcl: _ ■Tank Overfill I High-Level Sensor. Model:e)e _ '7"t. [,gyp ■ Tank Overfill/High-Level Sensor. Model:�� new Fe sp Q f7thcn(s w if a uiptn�stt and Model in Sex tion Ir I&Re 2). O C)Eher(spycif a ui. =Lt and model in Sm-tion L on Pae 2)• Dispenser TD: *r12 __ dispenser TD: 49 +,i .. Q11 Dispenser Containment Scnsa(s). Model:ZA- Po-,Ir'I.- 5 B Dispenser Containment Scasor(s). Model:R-f-You-/00--5� ® Shear Valve(s). valve(s). ❑ Di!�cr Containment 1'125 s and C s). U Di=Containment FI s and Chain (s). Dispenser ID: jv YZ 'Dispenser ID-_7 8 111 DiWcu%er Containment Senso s Model: - cam• -/e0-__4Z_ IN Dispenser Containment Sen xi s. Model: RC-4eaav-/0e 1f Shcxar Valve(s). 11 Shur Valve(s). O Diycnscr contaiinac to Ploa s and Chain(s). ❑ Dispenser Containment 17104d(s)and Chain(s). Dispenser ID: f eI/o _ Dispenser ID: ® Dispans r Containment tiensor(s). Model: Model:Re-'i'4xp, -lie--5 r Shc-uar Valve(s), ® Shear Valvc(s). 13Dibpcnscr Contaamment.1;125 s and Chain(s). ❑ N12EM Containment Float(s) and Chain(s), ? *if the facility contains more tanks or dispensers,cony thi&latero. hOude information for every tank and disVunsa at the facility. C. Certification - I certify that the equiptnew; identified in this document was inspected/serviced its accordance with the manufacturers'guidelines. Attached to this Certhlcation is information(e.F,manufacmrers` checklists)necessary to verify that this information is correct and a Plot Plan +hewing ft!layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy ofpc report; rr heck all that apply): ❑Syyfcm sct-up Alarm history report Technician Name(print): 4�/2 eZ- `'(�,�,l,�r.ale � Signature: Certification No.: Do 6; -OS-O( 53 ._.. .�._.� License.No.: b 3 -/6 V Testing Company Name: Dialysis North Phone No.: ` 530 ) 275-6667 Site Address: / Al 37A@k reAGY 9-6-;„-Ir-„ &10,0 At - . Date of Testing/Servicing' ,Page I of 3 03/01 Monitoring System Certification