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—. Iv a.+ i "AA11Tl IIr__ 1-11 1,11,J1.14 For UJa 8y All Jutirdictiona Wuhan the Stare f oCahfbrrtta Xuthortty Cited.- Chapter 6.T, %ahh and Safety Code:ChaPrer 16. Divirion 3, Tire 13. CaPrforni i Code o/Kcgri grin+rs nis form must be used to docurnem testing and servicing of munikoring equiprnent. If more than one monitoring systctn control panel is installed at the facility, a c crate certification or report must tq_kL pare fvr ~Kath monitodalz systern ggatlrol vnnel by the technician who performs the work_ A copy of this forth must be provided to the tank system Owner/operator. The ovwncr/operator must submit a copy ofr agency regulating UST systems within 30 nays of test date. Instructions are printed on the'=, A. General Information JA N 0 K: �1� 9 ZOOz; Facility Name: U r" l��, _1� � HE Site Address: city: dip. g Facility Contact person e Contact l'htyue No.; { �C t7Q � -j q q °.1+Lef%lodcl of Moaitoring System erre_ • Date of Tcsting/Srrvicing: I �j 16 B. inventory of Equipment Tested/Certiried Check the appropriate boxes to Indicate specific equipment inspected/serviced: ad : Tank WD. In-`lank Gauging Probe. Model: In-Tank Gauging Probe. Modcl. Annular Space or Vault Senror. Model; ,W'Annula€Sparc or Vault Sensor. Model: Piping Susarp(Trench Sensor(4). Model. _ _ )J piping Sump/Trench Sensor(s). Model: ❑ Fill Stamp Sensor(s). Model: ❑ Fill Sump Sensors), Model: Mechanical Line Lcak Detector. Model: Mechanical Line Leak Detector. Model: ❑ Electronic Line Lcuk Detector. Model. ❑ Electronic Line Leak Detector. Model: Q Tank Overfill/Hi4h-Level Sensor. Model: }�Q 'yank Overfill/titgh-Levcl ScnsOr. Model: " se , pispcnr Contairrwmt Scmor(s). Model: _ Dispenser Containment smsor(s), Model Sher Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Vispcnmr Containment 1=loags)and Chain(s). ® Other(specify equipment types and model In Section E on Page 2). ❑ Other(specify equipment rype end model in Sextion E on Page 2). Tank ID: Tank W: Q ]n-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault sensor, Model ❑ Piping Sump/Trench Semcir(s). Model: Q Piping Sump i Trench Sensor(s) ModcL ❑ Fill StmpSert.ser(s). Model: ❑ Fill Sump5cnsot(s). Mock]: Mechanical Line Leak Detector. Modct ❑ Mechanical Linc Leak Detector. Modcl. ❑ Electreric Un--Leak"Detector. hgodel, O Electronic Line Leak Detector. Modri. ❑ Tank Overfill t High-Lcvcl Sensor. Model: ❑ Tank Overflll t High-Level Sensor. Model: ❑ Dispenser Containment Scnsor(s): Model; IJ Dispenser Containment Scnsor(s). Madel: U Shear Valve(s). ❑ Shear Valve(s). ; ❑ Dismnscr Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(e)- d Oithcr(spectry equi t and model in Section E on Page 2)_ 1 ❑ Other(specify equipment type and model ir1 Section E on Page 2) 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. munufscturers' checidists) necessary to verify that this Information is correct and a Site Platt showing the layout of monitoring equipment. For any equipment capable of generadrij such reports,[have also attached a coPy of the(check all char apply): ystern set-up report; Alarm History report. Technician Mama(print): a . . . q gnnturr ,r r Testing Company Name' _, ActL.kS nC IbApe�= , J, tnr. '— pltone Nu.: CALM-09 Paget L of 3 1 trls✓!9 }