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Hpr 02 10 10:43a Elit IV Contactors 120946"'342 p•1 MONITORING tSYSTEM CERTIFICATION 11-11��VW EDD -4whorim Cited: Clraprer 6.7. liealrh and Sgery Code: Chaprer 16. D isroer 3. lrrle 23. Calrfornia Code or'Regulazionr APR 0 5 2010 This form must be used to docurn=t testing and servicing of monitoring equipment. If more tb one monitoring system control panel is installed at the facility, a $(Monte certification yr report must be V11LN lr HEALTH �.l i each m9nitoriny sY= con=11 Rancl by the technician who pt rfozms the work A copy of this form l��TiSERVICES provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. histructions arc printed on the back ofrhis page. A_ General Information Fac=liry Name: Bldg_ No.' c c AdVN City: Zap:. q Facility Contact Person ' L -((i t �XM Conn,a Phonc No_: { 2M) _i&b_-"� MAc Modcl of Monitoring System: _ LZ5SM Date ofTcsting/Servicing: H- Inventory of Equipmeaa! T=t-_d/Cerld1led Check the ro riatt bow to Indicate specilk equipmetit ins ectcdlserviced: rID: Tat>k ZQ- !Tank Gauging Probe Model: % 1n- Tank Gaugvlg Probe_ Modcl: Annular Spate or Vault S=ot. Model: _ R(Annular Space or Vault sensor. Model: 0 Pipmg Suraprr=6 Setsar(s}. Model- ❑ Piping Surnprrrench Scnsor{s), Model: XFill Stuup.Seasot{s). Model: eFiil Sump Seawr{s}. Model: ❑ Mechanical Line Irak Dmecior_ Modd: ❑ Mechanical Line Leak Detector. Modd: fflpElectronic Line Leak Detector. Model: 0 Electronic Line Leak Detector, Mode}: Tank C --fill / High -Lend Sensor_ Model: _ 13 Tank Overfill / Fiigh-Level Stwor. Model - Of Disp-ucx Containtrtew Senwgz). Model: D ❑ Dispenrer Containmegt Sensor(s). Modcl. _ 0 Shear Valve(r). ❑ skc2r va)ve(s). 0 Diaperser Coruainment Flow(s) and Chain(s). 0 Dispenser Cozzainm►wslox(s) and Chatn(s). 0 ()d- (sPcczify equipment type and roodel in Section E on Ps •c'_ _ 0 Others ci a tri nt and rnodd in Scrtivn E on Pare 2). Tanis II7: Tank ID: In -Tank Ganging Probe. Model: ff to -Tank Cuuging Probe Model: Annular Spaceot vault Sensor. Model: Annular Spa -or Vault Sensor. Model: Cl Piping.Sumprfrrnch Scr or(s). Model: ❑ Piping Su P(T—ch Serer s;_ Mod:., ❑ Fill Surnp Scrnor(r). Model: a Fill Sump Sensor(s). Model: Q :U cdmnitcal Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: �l Electronic Line Leak Dexetmr_ Model: 0 Elearoaic Line Echis Driecior. Model: 9f Tank Overfill / High-Lcvtt Sensor. Model: if Tank Overfill / High-trvel Sensor. Modek ❑ Dispenser Corttainmrnt Senror(sj. Model: D Dispenser Conmintnmt Sensor(s). Model: 12 Shear valve(&)- 0 Shear Velvc(.I)_ 0 Diw-- Contammeat Float(s) and Chain(s)_ ❑ Dispcnsa Containnrat Floar(s) and Chain(s). 0 Othcr (s ifv rlype and model in Section E on PaRe 1). 1 ❑ Orlser eci tri==m rypc and model in Section E on Pads 2). C_ Certitficat10n - i certify that the egoipmeet identified in this doeutnent was Inspected/serviced in accordance with the mntufic[tttzra' CuWd lama, Attarbed to thfs Ce"It""m is iuformatinu (e_g. watufacturerV checklists) tttcessaty to verify thar this information IS correct and a Site Plan showing the layout of.moilhoring equipment- Far any equipment _capable of generadug larch rcportsi I )-rave also attached a -copy of the (ckeck Off thar.apPW: ❑ Systera set -tip rc rt - pa , i ICC, LECsI•i - n rm khtw v report_ Technician Name C=A. No � tom: •i Si r� ��y�' j Tcstutg Company Naasc_ Pftoae No_: l CALM -91 Pa c l