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Jul 15 10 07:45a Elite IV Contactors 12094616342 P.1 MONITORING SYSTEM CERTIFICATION TION cJlLc�� Fe:r- .4uthorin, Cited' Chapter 6. 7. Health and Safety Code. Chapter 16. Division J. Title 13. CaWornta Coote ar'Regutarions P This form must be used to document testing and servicing of monitoring equipment. If more than . , e rnohitoring system control panel is installed at the facility, a stearate certifcatioo or report must be p. wed for each monitor' =l lzancl by the technieian who performs the work. A copy of this form must be provided 'to the tank system, ownertopmtor. The owner/operator must submit a copy of this form to the local agency regWating UST systems withiu 30 days of test date. Instructions are printed on the back of this page. A. General Information Facility Name: Bldg. G j � � S i Lam.. cs_r' W °` � Bldg, Na.: S:Ee Address: Ci 1.,�-- l— �. Com' L a e A-41 Zip: ! j_� Facility Cataract Person Contact Photic No.: ' 1 Ol MakelMadel of Manito•.it:g System LL4L Pna _5 3.5 6 Date of Tcsnng/Secviciag: B. Inventory ofEquipmeot Teste_&CertWed Check thea rodate bona to tatdlcate s equipment itis ected/servfced: Tank IB '2i g 1 Tank iJD:_� 0 in -Tank Gauging F� Model: O In- i anlc Gauging Probe. Model �Atx+vlaa Space or vault Sensor. Model: / �40 Annular Space or vault Sensor. Model: Q Piping SISOWTrauh Srnsor(s). Model: Q Piping SamprTreach Sersar(s). Model. 0 Fill Sump .Smvn(s). Model: 0 Fill Satrap Sensor(s). Model: 0 Mechanical Lira Leak Damon Model: Q Mechanical Line Leak Detector. Model: 0, Electronic Line Leak Detector. model- Q Aecgmonie Line Leak Detector Model: 0 Tank Overfill ! High -Level Sensor. Model: Cl Tank Overfill t High -Level Sensor, Model: Q Dispenser Comtsmrmat Sts"s). Model: Q Diisptlnser Containsent Sensoor(s). Model: 0 Shear Valve(c)- Q Sheri, vslvc(a). 0 Disptatser Containment Float(s) and chtin(s). d Dispenser Contaiarneut.Float(s) and ChWn(s). ® Oth s t send model in Section E on P•. c :. Q Other (!l!.ccifY cQuiPaicat type and model in Section E on Nee . Tank @: Tank ID: 0 In -Tank Ganging Ptofm Model: 0 In4ank Gauging Probe. Model: 0 Annular Spac-eor vatrltScasor. Madel: Q Annular Space or Vault Sensor. model - Q Piping.SttmpF! r=rtch Senaor(s)_ Model: l) Piping Susnplrrench Sersor(s). Mo :k 0 Fill Sump Seatsor(a). Model: a Fill Sump sensor(s). Model: 0 Mcciranicad Line Leak Detector. Model: CI Mechanical Line Leak Dctectot. Model: Q Electronic Lase leak Detector. Model: Q Electronic Line Leak Detector. Model: 0. Tank Overfill / High -Level sm$or. Model: Q Tanis Over{tli i High -revel Sensor. Model: Q Dispenser iruatatt Seasor(s). Model: 0 Dispenser Containtnent.senser(s). Model: Q Shear vatve(s)). 0 Shear Valve(s). ® Dispenser (aacainmcvt Float(s) and Chain(s). (3 Dispense Contairtn ent Floar(s) and Cbain(s). Q Other (s i ui x rMc and sttodtl in Sectio E on Pai ze Tl. t} Other eccgu3pantnt pope and model in Sccrioa E on P21C T). C. Certiffcutioll - 1 certify that the equipmeut identified in this document was Inspected/serviced in accordancewith the Wit'sufsettuers' gukWimes. Attached to thls Cerilllcatioa is inforruation (e.g. toxon€acturers' checklists) necessary to verify that this information is correct and ser Site Flan allowing tate layout of moisitoring equipment. Far any egatiptnettt eapabie of generating such reports, I have slap attached s-coFe of the (ckeck atf dhw apply ®Syatcm st t-tcp report; 0 Alato history report Technician lK== (print)- t ! n {Signature- Testing �.� Ceat.JLie. Na: Sigsatrrrc Testing Cottapany . A JPbaxte No.: cat,Ra of "" i�.i� ryI ,. 9y�� t11 , Pik --•- - -- - W431" y,i �Okfo JUL 1 =tea 2010 ` A;V l �. l