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MONITORING SYSTEM CERTIFICATION For Authority Cited.- Chapter 6. 7, Healthsa dd . afety �'vde Ay All te,. Chactiom Within t j)jiat„ 3 California 231 Culifornia Code =rions This form must be used to document testing and servicing of monitoring equipment. - the9-A se cetti n Po Firr He o by tho tu;hnic; u who perfbrmtg the work, A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local ngency regulating UST systems within 30 days of test date, A. Generallnformatiou Facility Nunn; Site Address: Facility Contact Peron: MakeModel of Motutoring System: BIdg. No.: fan7li y- XC -+_._i.--- Cm'.Zip: Contact Phone No.:— Date of Testing/Servicing: B. Luventory of Equipment Tested/Certi>i'"red l^. Tank M: --I In -Tank Gauging Probe. Model: Annular Space or Vault samr. Piping Sump I Trench Sensor(s), Modvk. -� Model: Fill Sump Scusor(s). Model: Alanieal Line leak Detector. _ Model: Ll Xeetronio Line Leak Detector, Model: El Tank Overfill 113igb_Levol Senior. Model; El Other (specify eq►toent type and model in Section E on Page 2). Tank 1[D: ❑ Other (specify equipment type and arodol in soction i on !j-Iu-Tank Gauging Probe, Model: [] Annular Space or Vault Sensor. Model: d PipingStm,p / Trench soneor(a). Modal: © Fill Sunip sensor(s). Model; Q Mechanical Linc Leak Detector. Model: d E]octroaic Linc Lral, Dctoctnr. Model: ❑ Tank Overfill / High-Level.Scnsor, Model: Ll Otbcr (specify equipment type an¢ model in �cction E on page 2). Dispenser II1: i [�Dispcwcr Containment Somor(,). Model ++ Dispenser Coutaiamcnt Floats) and Cbaiu(s)_ Dispenser ED: Dispenser C:ontninmentSCSCIF(3). Model: 0 Shear Valve(s), ❑ Dispenser Containment Float(,) and Chain(s), )dispenser 11): �] Dispenstrr Containment Senspr(s). Modal: ❑ Shear Valve(s), ❑ bispcnser Containment Float(s) and Chain(s). `if tiro ftrelllry contains more C. Tank ID: 0 In -Tank C,augting lrrobe. Model: fiKAanalar Space or Vault Sonsor, Model: Piping Sump / Trench Scasor(s). Model [] Fill Sump �orlSor(s)- Model; Mechanical Line Leal; petector. Model: q + [l Electronic Line Leak Detector. Model: j �! ❑ Tank Qverfill / High Level Sensor. Model: [l Other (spceify equipment type and model in Section E on Page 2). Tauk ID; ❑ In-T4111C Gauging Probe- Model: ❑ Annular Space or VSWt Sensor. Modcl: El Piping Sump / Trench Seusor(s), Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak pets -&or. Mc ,&l: �T Q L?leetronic Line Leak Detector. Model:- ❑ Tank Overfill / High-Lcval Sensor. Model: ❑ Other (specify equipment type and arodol in soction i on ,Dlspemer ID: Dispenser CApptinmant Scnsnr(x} Model: C Shear Valve(s), `� [l Dispenser Containment Float(s) and Chain(,). Dispenser Ili: _ _] . ti > l Dispenser Containmarrt Scmor(s). mo&17. ❑ Sheer Vaivc(s), ❑ Dispcngar Containment Float(s) and Chain(,). Dispenser ID: 0 Dispenses ContainmentScnsor(s), Model: CJ Shear Valve(s), - [] Dispenser Containment Float(,) and Chain{s}, or dispensers, copy this form, lncludo information for ev �}' tank and dispenser at the facility, Gertfeat'on -1 certify that the equipment identiflad is this docunwat wag Ins guidelines' Attached to this Certification is information (e,g. ruanafacturers' checklists) n y n amordance.with the manufacturers' correct and a & e -plat asap showing the layout of monitoring equipment For any seta# went eapAble of �eneratia such �nfor t nave uy verify that this informatiga is also atWehed a Copy of the rraporti (check aft drat apply): A System set-un,� Alarm history report' Technician Name (print); Tan Fontana V1flat,�UQ C� .ifir Barr No.: V.R. A2S$86 ICC 52892g UT SignaEtue: Comp Name: ice se _ Testing a1lY 11.S.`t, C o.: A. 846 nce TesV: inc. Phone No.: 2119 a9g4,489 Testing Company Addref, h.p, Box 580 Cares GA 853Q7 TTN.-wg - Data of Ta3stiuglScrviciug: � �'L I/d 9G1;''0 3�1"d (=A svo � 10 9L9� > 8h9Z bZ :9Z ZZ9Z/T ,'ZL