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SERVICESTATIQN MAIN*NCE FAX NO. ;916 371 2540
<br />Wec- 89 2005 09:47RM P2
<br />MONITORING SYSTEM CE
<br />Authority Cirerl Chuptar t5 7 Flealtl Sartd Sae RTr{ �C'A7'J(�
<br />By X11! y Code'. Cha Yt'itlrrit the State r>l'�al far�ta
<br />This for1n must be used to document testblg and sor•vici Code; lhapten 16, .Divirrvn 31 7yt1e 2I Cal ornja Cod, a
<br />fes''—�t� unrtorrr iS Pmonitorittg cquipnient. ��e'�latraru
<br />�Y9tCII1 C037t�'Ol non
<br />system Oy{t dateperSfRl. The OWnerIO ert}COr he to hn'c'a q h �A CEIf#ifirar:. _ _ .
<br />----tee by the tec}ulgcian who perforans the work. p, copy .s�,r rear rt nu��I be re
<br />days of test date. py ofthis form roust be 13r`ovldcel to the tank
<br />py of this force to the local agorrcy regulating UST systems within 30
<br />A. General111formation
<br />Facility Name: t . 1
<br />Site Address:
<br />facility Contact parson:
<br />Make/Model of MprpilurinLSystem:.
<br />g _ Uyc �
<br />$� Inventory of Equipment Tested/Certi-fied
<br />Check the >a to ste boxes to IkIdlev+ . e..- ,a - . - .
<br />Tank IR _
<br />� In -Tank 7,7 7: !n' Por be,
<br />0 Annnular space or Vault Sensor.
<br />18 -piping Sump I Trench Sensor(s),
<br />4 Fill Sump Sensor(.),
<br />J� A2echariical Line Leak Detcctor.
<br />❑ Electronic.Line Leak Detcctor•.
<br />Tank t)ver[lll ! 1Tigh-Level Sensor
<br />❑ Other s cci a tri sent a And
<br />Tank P:
<br />@ In=Farils Gauging 1'ro
<br />Annular space or Vault Sensor•
<br />�t Piping Sump /Trench Sensor(s),
<br />0 Fill Sump Sensor(,),
<br />a Mccllartical bine Leak Detector.
<br />❑ Electronic Line Leak Detector.
<br />'1'ai,lc Overfill / l-figh-Lavcl sensor.
<br />Dispenser ID: 4-.
<br />❑ Dispenser Containmerrt Sensor(s),
<br />2 slicer valvo(s).
<br />Model:
<br />Model:��
<br />Model:
<br />Modal;
<br />Modcl:
<br />Model:
<br />rrtodcl in Secifon E on Daaer
<br />�_
<br />Model: l�
<br />Model:
<br />Model:la-z�
<br />Model^
<br />Model:. .. -rad
<br />Modal:
<br />Model: _ ts�,r'7: a
<br />odel in Section EE on.._
<br />Modcl:
<br />--•a pjUx1 Luuwnrnent r7oat s Ariel Chain
<br />Dispenser )'II:
<br />© Dispenser Containment Sensor(s). Model:
<br />0 Shear V¢lve(s),
<br />I -is carser Contalntrrcat Floats and Chain s
<br />Dispenser 1D:
<br />❑ Di.penscr Containment Scnsor(s). Model:
<br />D Shear Valve($),
<br />C1Disnenser .-A
<br />'If the facility contain, more tanks or dlspc vers, copY alis fomt
<br />Bldg. No.:
<br />City:
<br />contact phorle No, Zip;_
<br />= Q DWO of 7'esting/Servicing;C3 / ,rG .... -
<br />Tank i1I):
<br />=t trr�Tmlt Gauging h-obe,
<br />0 A�nnulur Space or Vault Sensor.
<br />a Piping Sump /Bench Scnso,r(s),
<br />0 Fill Su np Sensor(.).
<br />Mechanical Linc Leak Detector,
<br />0 Electronic Linc Leapt Detector.,
<br />t TAnk ovcrtill /.High -Level Sensor
<br />O Other fsneciir, .... ,__. - .
<br />Madel: cY .v .7
<br />Modal;,�y� s�
<br />Madel:
<br />Model:
<br />Model:}1/1(F
<br />Model: ~ --
<br />Model: =a te,.11 -
<br />Tank ID,- '""' lj,vaec in Section 1✓ on P2 f
<br />4 In-"t'atrk Gauging�G --.
<br />❑ Annular Space Vault
<br />Model:,
<br />or Senor,
<br />E3Sung
<br />n' S p pi art /Trench Sense s ,
<br />4 Pil] Sump sensnr(s), )
<br />_
<br />Model:
<br />l4tu l:
<br />L� Mc chttnictll Line Leak De
<br />Model:
<br />TM
<br />tt�ctQr.
<br />❑ Electronic Line L.eak'Dctoctar.
<br />Model:
<br />D Tatrk 0vcrltll /Hlstr-p,Gvel Sensor.
<br />❑
<br />Model: ,r. __ ....
<br />Model:
<br />Other s ec' e U1 n1Cnt a and rnodel In SECti
<br />Dispenser ID: on E on Pa c Z .
<br />❑ DhVenscr Contairinient Sensor(s),
<br />tk5 Shear VaIve(s),_--
<br />Madel:��4..'
<br />Dispenser ID: - - » ,• _
<br />0 Dispelat Contain
<br />nt Se.
<br />1Gi Shear Valve($),
<br />Dispenswr 1(D; - _- --
<br />0DispenserContainnx�ntSensUr(s)•
<br />U Shear Valvc(s).
<br />Include intormAaion for every dank and orspemer at the thcility.
<br />C. Certification - I certify that the equipment identified in this document wax inspected/serviced in accordance with the manuracturers'
<br />gyla f; « . t�rvcdrd co tarts Certification is tnforniAtion (e.g. mtroufaeturers` chocklIaks) ripaeasary tq vtrl iPy that this inrarm>ttlgn fy
<br />correct rend A Plot Plan showing the Istyotit of mgnttoring equipment. For any a aip capable of eneratin such
<br />�lttachad A Eppy Of the report; check all thut a.,po), fi7 System :act -up g g reports, I have a,$A
<br />Technician Name (prilit): t laJrtl history report_
<br />Signature: --
<br />Certification No,:
<br />License. No.:
<br />Testing
<br />Cotnptany Nellie:
<br />Site Address:
<br />Phone No.:�(�}�;
<br />� „��'
<br />_...__ Date of'-resting/Servicing:
<br />Monitoring System certification Pagc 1 of 3
<br />013101
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