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MRINIWNCE FAX NQ. :915 371 2540
<br />WDiyC. 28 2005 04: L,?'M 132
<br />MONITORING sYsTINJ CrptT
<br />,4uthority Cited' C'haP ter 6 q For Use By ,111 jzjrjsdietionx Within tfre State to � -,ICA TION
<br />Health and Safety Code; Cha ter 16 Division 3 Title 23
<br />This form must be used to rlootunent testis P , C"al forrtla Code a
<br />r hg end servicingfli'egicla7lorts
<br />system ve:1352ti23d1Qj b the tee of inanitoring equipment.
<br />wrier.1%cratur, Theo y hnician who performs the work, A iflratiox,
<br />days of test date. 'vncr/aperator must submit a co ra aced
<br />copy of this fann must be provided to the tank
<br />17Y of this form to the !coni agency regulating UST systems within 3Q
<br />A• Ge>perallrlforrllation
<br />Facility Name: r , 1. , , _
<br />Site Address:
<br />Facility Contact Person:
<br />"4ke/Madel of Monitoring System:
<br />13- Inverto ilxof Equipment checkthea ro lested/Cer�ti-
<br />fedboxn
<br />Tank ID: - „+,cnr,n9 eeted/®ervlc
<br />In-7"s111k bloging Pro e. MedeJ:
<br />i� Amular.Space or Vault Sensor, 94�
<br />iii Piping Sump /'I'rcueh Sensors , ModeJ; H y
<br />❑ Fili Sum 5enso s , () lvModcl:
<br />p ') Model: _
<br />IN Mechanical Linc Lcak Detector, Model: j , o
<br />❑ Electronit bine i,eak bctcctor, Model: ^
<br />{R Tank nverflil ! 1418h,Level Sensor. Model: /
<br />.7�Q0_
<br />Cl Otho eci ui meet . and model in Scc:clain L oil Pa e 2
<br />Tank Ib: _
<br />15 In -Tank Claiuglug 19robe. Model: .�•�
<br />U Ac:,;:ir: Space or Vault Sensor. Model
<br />Piping S'samp /Trench Smsor(s), Model: -
<br />❑ Fill Sump S'cnsor(s), Model: T
<br />0 Mechanical l .ine Lcak Detector. Model _Z to` T
<br />❑ BJectronic Linc U4 D:.ector, Model:
<br />¢! Tank OvczlTll / High -Level Sensor. 4iodcl: +'r
<br />Ll ©t h.: (speeil"y eyu:5r .:rt type and modc::n Scction V ori page 2)
<br />Dispenser JID'
<br />Cl Disp-•=r Coatuirime:a Sensor(s). Nlodcl:
<br />R She-- Valve(s).
<br />M D .==r Conwinreat Flont(a) and Chain(s).
<br />Dispenser ID: :2 1 S.0 ,_—
<br />❑ Dispenser Contnini:lent Senssr(s), Model:
<br />Q SAmr Valvc(s).
<br />B Disponscr Containment FIt+ae(4) and Chain(s
<br />Dispenser ED:
<br />t❑ Dis; xser Colatainmellt Sensn-(s). Model:
<br />Cl Sheri Valvc(s),
<br />❑rltan";t—_ Containment Plod, s) and Chain(s).
<br />City: Bldg. No,: __ [�r�
<br />Contact Phorle No.: (,� Zhp,
<br />�)
<br />Date of '1esting/,Servioiug: //
<br />Tank Ili: I
<br />V In -Tank Gauging Probe,
<br />m Annular Spaco or vault Sonsor,
<br />a piping Sump / Trench Seruror(s),
<br />Z1 Fill Sump Sensor(s).
<br />CO Mechanical Lino Leak Detector,
<br />Cl Electronic Line Leak Detector,
<br />ATank overfill ! Nigh.I,cvc ] Sensor.
<br />❑ QhLr
<br />Mocks:
<br />Model.-
<br />Model:
<br />odel:Model:
<br />Model: !t/i
<br />Model:
<br />�`---
<br />io
<br />Tank W. n cotton sin Page 2).
<br />C) Int -Tank ti<ttuging probe,
<br />Ci Anni,lar Space ai' Vault Sensor.
<br />Model:
<br />Q piping 3wnp / 'Tench Sensor(s).
<br />Model:
<br />Model- r
<br />❑ Fill Sump Sensor(s),
<br />Model:
<br />P Meclianioal LJne Leak-Dettctor.
<br />Model; �m
<br />❑ r.,6tronic Line Le' ak Detector.
<br />Model:
<br />❑ Tank pvertill / lligh-i,evcl Sensor.
<br />Model;
<br />`7 Otfler s Ri a ui tlnetlt 2 slid inodei sal Section E o„ Page 21�
<br />Olsponacr IIS:
<br />❑ Dispenser Conrwnment Sensor(s), Model:
<br />RF Shear Valve(s).
<br />D%penser YD: �7
<br />❑ Dispenser Containment Settsor(s).
<br />C1 Shcar Valve(s),
<br />and
<br />Mipenser ID:
<br />0 Disinnser 6ntainment Sensor(s),
<br />❑ Shcar Vulve(s),
<br />❑ 1]ispenser Containment Float(s) and
<br />Model:
<br />Model:
<br />sif the trci;:ty contains more tmks or dispensers, copy this form. Include information for every trunk and dispenser at the facility,
<br />C, Certification - I certify that the equipment identified in tills document was inspected/serviced in accordance with the manufacturers'
<br />guldetines. Attached 0 this Certification is information (e"g. manufacturers' checklists) necessary to verify that this information i9
<br />correct and a Plot Plain showing the layout of monitoring equipment" For any equip capable of generating such reports, I have also
<br />attached a copy of fire reportz (check 411 shad apply): ;a System set-up In history repprt
<br />Tochniciau Name (print): .,,LU,w._-- Signatilre: _
<br />Certif;catiau No. a 1 7 / License. Na.: Cft Ca 1117 L/
<br />Testing Company Name: t M_ -�r Phone
<br />Site Address: _� rte.... _-. Date of Testing/Servicing: /2_
<br />Page 1 af3 D3ltit'
<br />Monitoring System Certification
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