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H 111JIN Isar Use BY All Jrttixclictfvns WtrAfn the State of Catifo lia , * Authority Chad: Chapter 6.T, %alth and Safety Gude:Chapter 16,Divmorr 3, Title 23, Calrfnmia Code PIRRgotinvas IT This form must be used to document testing and servicing of rnonitoring equipment. If more than vne manitaring systcm control panel is installed at the facility,asate certification or repolc t test be p L._fQ r 2@2h—monitodulz system contlyl panel by the technician who performs the work_ A copy of this form must be provided to the tank system owner/operator. Tle owner/O1,; r gust submit a copy of this form to the loical agency regulating UST systems within 34 days o �cst date �care printed on the back of this page. u � A. General Information - _ APR 20b3 Facility Ntune: haZ! I Wa" _ Bldg.No.: 1 Site Address: �ft �1 t 1`�l �Rt� y D til isE Zip ��rCES .� _ yy A614 Contact Person: 1 4{'Gr+._ Contact Phone No..,�� :aMakelModel of Monitoring System C 1 (' Cs Bate of TestinglServicing: G8470SU-022 B. Inventory of Equipment Tested/Certified; Check the appropriate boxes to indicate specific equipment inspected/serviced- Tank TD: Tank I.D. � ,, Injunk Gtiugt g Probes Mvdcl: In-Tank Gauging Probe_ Model; Annular Space or Vault Sensor. Model: J14 Annular Spacc or Vault Seauor. Model: Piping Sunip 1 Tremb Straor(s). Model.-6 7 4 if )dPiping Sw W/Trench Sensor(s). Model: ❑ Ftli Sump Smor(s). Model: ❑ Fill Sump Sertsor(s). Model; Mechanical Line Leak Detector- Mode.: Fx-IV X Mcchanial Line Leak Dcicclot. m0eel: - Q Electronic Line Lcuk Detec cor_ Modef- ❑ Electronic Line Leak Detector. Model: Tank Overfill t High-Lcvei Sensor. Model: iY, )8 Tank ser OveafiIf/High-L,ewl Scnsor. Modell: c DispenContalnrmmt Simsor(s). Model: ` -2 Dispenser Containment Smsor(s). Model: shear Valve(s)_ shear vaive(s)_ Q DispenscrContalriment Floats)and Chains). Q Dispenm Containment Flmgs)and Chain(s)_ ❑ Other(specil)+ aipmnt type and model in Section E on Pagt 2). ❑ Other(specify equipment type and model in section E on Pagc 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe- Mc&I. © In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model, X Piping Sump t Trench Sensor(s). Model:(2)7 q �f}- fit). ❑ Piping Skimp l Trench Senor()- Model; ❑ Fill Sump Sensor(s). Model 13 Pill Sump Scnsor(s). Model: D Mechanical Line Leak Detector. ModcU ❑ Mechanical Linc Leak Detemc Modcl: Q Electronic t.irnc Leak Detector_ Mock]; Q Elestrornc Linc Lcak Detector- Model. ❑ Tank Overfill c High-Lcvel Sensor. Model: a Tank Ov"1111 t High-Level Sensor. Medel: Dispenser Containment Scnsoris}, Model, ' - 909- 0 Dispenser Cont:anment Scnsor(s). Model: Shear Valve(s). Q Shear Valve;s). s Cl Disperim Corttarrnrnent Floats)and Chain(sy ❑ Dispcuser Containment Floats)and Chain(s). ❑Oilier( uiptrttrtt type and mode!in Section E on Page 2)_ 1 Q Other(specify cquipment type and model in Scction E on Page 2). C. Certification - I certify that the equipment identified in this document was inspected/serviced is accordance with tfe tnanufaet U-M' aoideli Des. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generadut such reports,I have also attached copy of the(check all that triply): System set-up report; C kr, 5 ['�,,r,rrs G�� `IS 1/51U 2y term history report. Technician Nacnc(print), i fl f kv�4�tCert./Lit.No.:51 FQ a 7,1235ignature, GAJ Testing Company Nattier 1t ]S zh C. Phone No.: CALM-int Page D of 3 g n in 5199