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MONITORRIG SYSTEM CERTM • SON For Use By All Jurfsdictians Within the State of Calr'forr ut. , ` Authority Caa L Cheater o.'., Health and Safety. Cade; Chapter. 16, Division 3, Tine 23, California Code of Reguimi'oas This form must be used to dtiairneat testing and servicing of monitoring gtapment. A sepsiate certification or report must be pn:=W ' for each momtorim-system en nrol panel by the technician who pe=rms the work. A copy of this form must be provided to the tank system owner/opmator. The owner/onerator must submit a copy of this form to the local agency regulating UST systems within io days of test date. A. Generrl Information Facility Name: t`_` rz-4m 03 44 �� - Bldg. No.: Site Address: (k 75-Y z # W K 2f, City- L tN t, ii f c,4, zip: ifs ;z -3 C. Facility Contact Person: A44., L Contact Phone No.: (_� Make,Nodel of Monimnng System: V EAQ7 iV f fit: &-f- -t< - 3� Z nate of Ttmting/Servicing:lZ B. Inventory of Equipment Testi Certified Cbeekibe xWeptleta bents m ipm� spalec eq meat �: T lU r 7% 'S�c l Tawk�: '3 --Le-1 N LCA ,4 PIEP 'S In_Tank Ganging Prohe. Model: .t/sFF - / a Tack Ganging praoc modiel: , W44C / Q Am tdar Space or Vault Sensor- Moder ��O -Y'7-lz 3�Xm dar Space or Vault Sensor. Model: "7 FD Q'Piping Somp/Ti®ch Sensor(s)- Modet:'"79 C- Q'piping Sump/ Trench SensWs). Model: 7 FVP 7RQ�7R1 OTM Snow Sea sms). Madel - Rot -M Sump Sempr(s). Model- '7fV79G-ZiWj 011echaoind line leak Detector. Model• i'Lbt.--".2rnc 2"Mcchaucat Line Irak Dactux- Model: 9rCri-,,+� Zc) Cl Electronic Line Leak Detector. Model- 0 Elecnrniic Lice leak Derixmr. Modet- 0 Tank Overfill f high -Level Sensor. Model: 0 Tank Overfill f Ifigh-Levet Sensor. Model ❑ Other (wecifv and model in Section Eon Page 2)- ❑ Other (saecify equipment=and model in Section E on Pa 2). Tanis )D: - loh'E=rn r u Tank ID: Tam Ganging Probe. Modet- U3� -( 0 lo -Tank Ganging Probe. Model: 3�A®ular Sparc or Vault Sensor. Model:-7`YY3F'C -Vm 0 Aamdar Space or Vault Sauser- Modes: 9'iping Sump 1 Trench Sensor(s). Model:' M. 4- 141, % - 0 Piping Sump / Trench Seasons). Mode: iii Snap Sensor(s). Model• % 0 Fill Sumo Sensotis). Model H M=bomrai Line Leak Detector Model: rY i> ot� ❑ Mechanical inti lemic Detectm- Modet ❑ Elec tanic Linc Leak Dctcemr. Model: 0 Electronic Low Leak Derecmr. Model: Tams Overfill / Huth JLevel Stasor. Model- 0 Tank Overfill FLgh-Level Sensor. ModeL ❑ Other ( and model in Section E on Page ^_)- 0 Other (snecifv - na:nt MS and model in Section E on Pap 2). Dug5weer ID: ! - Z- Disj a Uk all p1spenscr Comainmear Season 5),�Sodel: /�[f�i -7-'e' f .2'ISspeawa Containment Sensorial. modet- Vaive(s). xrht Vatvaw- 3 Manner Containment F)oaus) and Cham(s). 0 D!aunnott Fk at(s) and CMhoindnd(:s)%. ID:Cnn� _2 47= Mo%-t �mdel- - '-�'� d'>7:speaser Coma®mc 5eworis). irshearValve(s). Vatvc(s). ❑Lnspeuser Coatavtmeac Float(s) and Chain(s). ❑ Dispenser Containment FioWs) and Chaio(s). ' Diepensw ID; tT-v, Degas IR C�"D SpeasczCWtammeat Semor(s)- Model: %�Z'i'283' ❑Dispenser sri��m,-nr 3emod5). Moelti: '7 i�'� "'�'-)' Shear Vaive(s). 0 Shear Valve(sL ❑Dispenser Cootaiamcat FwWs) and Cbmn(s). 0 Dispenser Conreimucat Floaom and Onou(s). 'If the fatality curtains more tacks or riespeasas, copy this forty Include i formation for every tank and dispc at the facility. C. Certification - i e 4ity thak the "supmtai WeaWled in this deermenk win inspeakdTseroieed in seeordso et, wish the meaeafa s'. guidelines. Attached to this Certification s information (e.g. mannfaclnress' dnedCiists) nPcncan, to verify that Mitts information )s correct and a Pot flan showing the Word of moadtoongt For any capabie of generating such reports I have also artarhed a copy of Ute report; (check aU that appfy): KI J�eKem For aAburm history, repo�� /r Tecbmcm Name(prim): Asv,)j L iUlt-aaa[ Y Signature: Certification No.: License- No.: $D y ?7 a Testing Company Name: IA}xi c tzEsnrV Phme xo.:(S'S ) GG c) -` 5 '/3 Site Address: P,L, MOX i 3l v7 SACIe4AW itO R rt'S4 i "S Dare ofTestiolpSevicbW I ZZ/ '33 /03 Page 1 of 3 mlel Monitoring System Certification r .