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JAN-1-2002 04:18P FROM: :12094683433 P:3/8 MONI&ING SYSTEM CERTIFTATION For(Ise By All.herisdictions Within the State of California Authoridy Cited•Chapter 6.7,Health and Safe. Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and mi nicing of monitoring equipment. A S=rate certification or report must be RIPMM4 for each mgttitprirtg 5Y51001 V-PYaol panel by the technician who performs the work. A copy of this form must be provided to the lank system owner/operator. The owner/operat•)r must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generid Information Facility Name: FLI-11/G- � _ _ Bldg.No.: Site Address'-ZEQ1.�_J, vAe;& i 1111— Zr1 City. RSP®.0 cf. Zip: Facility Contact Person; If Contact Phone No.: Make/Model of Monitoring System: Rzb Date of Testing/Servicing:GLIA/ c,-V B. inventory of Equipment Tested/Certified Check dw a rlaso Wpm to Tank IID: . S-/.x.am f g:UaAL� . _ - Tank ID ` �- l.2,u�v G.au.��J `�l •....---....-- 6 In-Tank Gauging Probe. Model: ® In-Tarek Gauging Probe. Model: 111 Annular Space or Vault Sensor. Model: L. ay-z, 0 Annular Space or Vault Sensor. Model:"—gap-o SNZ O Piping Sump/Trench Sensor(s). Model:_g-_._=5tv ! Piping Sump/Trench Sensa(s). Model it+'t- 4 -//® .S ❑ Fill Sump Sensor(s). Model: d Fill Sum tp,%m. r(s), Model: 4 Mechanical Linc Leak Detector. Model: t!12 f; :rry 0 Mechanical Litre Leak Detector. Model: fv LJ� U 1 dcxttrontc Linc Lc-jk Detector. Madel: U Eleetrostic Linc Leak Detector. Model: Of Tank Overfill/High-Level Sensor. Model: ® 'Tank Overfill/High-Level Sensor. Model: -- Q Other egWyment t and model in Sacticm E Page 2). 13 Outer(. i tri and model in Section Ln Pa 2 . Tank 1D: 7=/..s. 10_ M In-rank Gauging Probe. Model- 0 In-Tank Gauges Probe. Model: 0 Annular Space or Vault Sensor. Model: C-V&t?-;-d M O Annular Space:or Vault Sensor. Model: 11 Piping Sump/Trench Sen"s). Model:R `/ka -ill -$_ O Piping Sump/Trench Sensor(s)- Model: U Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: D Mechanical Linc lAak Detector. Model: Q Mechanical Linc lx&Detector. Model: ❑ Electronic Line Leak.Detector. Model: L:1 1-2ectronic lane Leak Detector. Mode(: _ O Tank Overfill/I lig)t-L.evcl Sensor, Model: w ® Tank Overfill/High-IA:vol Scum. Modal: Q Other(specify equipment=and model in Section F.orf Page 2).__ ®(met and model in Section E on Pm 21 DlxpCnxer ID: °' / SSTDispenser ID: ye ® t)ispens eT Containment s). Model: e-- V • de.. a I)ispenser comae Ment aamr(s). Model;le-`fes &Shear Vaal*s). r Shear Valve(s)_ ❑ TN scr Containment Fls and C s. ❑ w Corktaittnterd!jMgsj and C s). Dispenser 3D /40 r:.r~T"', DispenserID: /'S S.l^ r Di�scr Contasnment Sensor(s). 1Model:A4E--'V4;' 4 -5 S Dispenser Con Sensor(s). Model:R -%- -0/l r MI Shear Valva(s). e Shear VWvc(s), Ll Dispenser Conmaunent Fl sj and C s. Q Dispenser Containtnent Piens s and JAS . Dispenser ID: 4'15 r IID: /G Saar_ 3 Dispenser Contaimrtent Sensor(s). Model: Yem .i�-S 8 Di. t Scnsor(s). Model:Ae-S�rao�•/moi.: :+ktrar Valve(s). ® Spar Valve(s). T^ ElDiRenser Containment Yl s and Chain(s). 9 DiMew Containment w7 s and Chain(s). &V the facility contains more tanks or dispensers,copy thin 41 rxm. Include information for every tank and dispm=at the facility. C. Cerffication - I certify that the e4nipmein ideotifted in this document was iln seIn accordance with the manofactumrs'guidelines. Attached to this Ceraication is inf tlon(e-& manufacturers'Checklists)memsaty to verity that this information is correct and a Plod.Plan showift tltth layout of monitoring equip For my egalpment capable of generating such reports,It have also attached a copy of the repowt(i7teack all that apply): ®S tem p ❑Akrm history report Technician Name(print); Signature; Ccrtificalion No.: TD��'..o ..__» License.No.: Testing Company Name: Dialysis North Phone No.: ( 530 } 275-6667 Site Address; /50! N� art enc 73A4 A) fw/P0N ! C4 , Date of Testing/Servicing: Page 1 of 0"1 114e nhering System Cemrication