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v Far Use 6),.141 Juriseliclions Within the State of'C'ulifbrnia Awhorily C'ileef: C'halVer• 6, 7, Health caul Sc¢ehv C'ocle; Chapter 16, Division 3, Tille 23, Ccrlifbrnia C'ocle of'Regarla/iolr,s This form must be used to document testing and servicing of mon'%nie ui inept. A se crate certification or report n1USY be prepared for each monitoring system control panel by the technician wnpyof this form must be provided to the tank sysn owner/operator. The owner%operator must submit arm cal agency regulatinf7 UST systems within 30 days of test date. y A. General Information SEP 2 4 2007 Facility Name:, ENV!Rqp�PUAT HEALTH Bldg. No.: Site Address:i1M60/ Gt Zip: /9`J Facility Contact Person: Contact Phone No.: ( ) q�+ Make/Model of Monitoring System: %� �'' Date of Testing Servicing: B. Inventory of Equipment Tested/Certified Cheek theappropriate boxes to indicates ed is equipment inspected/serviced: d�� Tanit ID:ging Probe. Model: A446'r / F ❑ In -Tank Gauging Probe. Model: e or Vault Sensor. Model• VD7 ❑ Annular Space or Vault Sensor. Model: / Trench Sensor(s). Model: 20$ ❑ Piping Sump / Trench Sensor(s). Model: nsor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: 79LD 'Z -00e' ❑ 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 (specify equi ment type and model in Section E on Pa a 2). ❑ Other (specify equipment t e and model in Section E Pa e 2). Tank ID: / Anc-r Tank ID: In -Tank Gauging Probe. Model: AJ Afst t ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 24f� ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 9( Mechanical Line Leak Detector. Model: STP -171-D ❑ 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 (specify a ui ment ty a and model in Section E on Page 2). ❑ Other (specify equipment t e and model i Section E on Page 2).Av- Dispenser ID: % 4- - Dispenser ID; -7-jf' J Dispenser Containment Sensor(s). Model: J4 Dispenser Containment Sensor(s). Model: Shear Valve(s). 12( Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Mojel--Zlfs Shear Valve(s). J KShear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 777 Dispenser ID: 2L Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). IR Model: it Shear Valve(s). Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Contaimnent Float(s) and Chain(s). X11 the tacilrty contains more tanks or dispensers, copy this torn. 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 /hart apply): Syste -u -Im history report Technician Name (print):-7Z4-Ajp Signature: " A' Certification No.:w' 5 Z y; License. No.: Ce _6ZEJ # *4 _5 U 7- 7& Testing Company Name:_ �r�S )- Phone Ggo - p/z Site Address:- Date of Testin/Servicing: 9 116107- Page 16/07 Page I of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing