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� MOORING SYSTEM CERTA'ATION RECENED For Use By All Jurisdictions Within the State of California NOV 13 2002 Authority Cited. Chapter 6.7., /lealth and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulattiijo�ns This form must be used to document testing and servicing of monitoring equipment. A separate certification oEIDotNM T HEA�,jH for each monitoring system control panel by the technician who performs the work A copy of this form must be provt o system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: _CU DI A100 T A?A9% P! _ Bldg. No.: Site Address: 5577 ... 1%�� / ff7Cc( ZKs'E rr City: _I� !N1)!cn/ Zip: 9f Facility Contact Person: .,5egm 4091 aoc)Contact Phone No.:( 2d9) qj6 K- 5C%S MakeModel of Monitoring System: —ie6EC � U A017- 01 77 -5 -356 Date of Testing/Servicing: J4 _/ 7 /_0L B. Inventory of Equipment Tested/Certified Chink the anmT .,.c m t`nA;__..,_— _ if me racmty contains more tanks or dispenses, copy this form Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspeeted/servieed in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report• chec/k all t—hat apply): ❑ System set-up ❑ rl�rpi hist r rt Technician Name (print): ) [.�G, rn r Signature: L_4, hr ��y Certification No.: tJ License. No.: Testing Company Name:�/tifi/t7l17f O Al /'�t�j� %fj r y�.__ Phone No.: _900) 66 0 Site Address: . /1 X / 3L S ,r'<II C/q- r•/SiC1 +' 305Date of Testing/Servicing: -ILI_7_/X)2, Page 1 of 3 Monitoring System Certification UXAS)l Ta k ID: Tank ID: -Tank Gauging Probe. K Model: Anular Space or Vault Sensor. I'H Piping Sumn/Trench 5enaor(s). _ Model: Model: efY. •- C9�1!Tank Gauging Probe. i� nular Space or Vault Sensor. fP,tping Sump Trench Sensor(s). -Model: Model: Model- 11it�Fill Sump Sensor(s). Model: O iY'yfrp -7!�� ill Sump Sensor(s). ZO Model: 7 - O ❑ -Mechanical Line `uak Detecin ❑ Electronic Line leak Detector. Model: Model: Lb -1DC17 p�� hanical Line Leak Detector. Yodel: 9'9 LYElectronic Line Leak Detector. Yodel: 9C D- 2inoe7 ❑ Tank Overfill / High -Level Sensor. Model: Cl Tank Overfill f High -Level Sensor. ❑ Other (s mi a ui ment and model in Section Eon Pae 2). ❑ Other (specify equipment t and -Model: model in Section E on Page 2). Tapk ID: Tank ID: Y> -Tank Gauging Probe. Model: % 61170 ❑ In -Tank Gauging Probe. Model: "nular Space or Vault Sensor. (;3�yi�ping Sump / Trench Model: 0 - Q Cl Annular Space or Vault Sensor. Model: Sensor(s). ZrFin Model: d - 2 ❑ Piping Sump/ Trench Sensor(s). -Model: Sitmp Seasor(s). Model: ❑ Fill Sump Sensor(s). Model: mlechanical Line Leak Detector, Model: 13 Mechanical Line Leak Detector. Model-- ectronic Line',eak Detector. Model: t_ ❑ Electronic Line Leak Detector. -Model: ❑ Tank Overfill / High -Level Sensor. Model: 13 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipmmtype and model in Section Eon Pa a 2). El Other (specify a ui ment type and model in Section E on Page 2). Dispenser ID: _'� Z Dispenser ID: a ❑ Dispenser Containment Sensor(s). Model: 875 .3 tl f ❑ Dispenser Containment Sensor(s). Model: c979c13S'O_2 9 ❑ Shear Valve(s). 0 Shear valve(s). B Dispenser Containment Floats) and Chain(s). B Dis nser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model:67q__2f.[k ❑Dispenser Containment Sensor(s). Nodek �7r7Y•Rf�O �2G� ❑ Dis nser Containment Floats) and Chain(s). 17 Shear Valve(s). ❑ Dis nser Containm=t Float(s) and Chain(s). Dispenser ID: ! Dispenser ID: / 417 ❑ Dispenser Containment Sensor(s). Model: O 5 N3SLf - 2(7Q ❑ Dispenser Containment Sensor(s). Model: 0 7 � zQ 17 Shear V_lve(s). ❑ Shear Valve(s). IlDispenser Containment Float(s) and Chain(s). ❑ Dispcnser Containment Float(s) and Chain(s). if me racmty contains more tanks or dispenses, copy this form Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspeeted/servieed in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report• chec/k all t—hat apply): ❑ System set-up ❑ rl�rpi hist r rt Technician Name (print): ) [.�G, rn r Signature: L_4, hr ��y Certification No.: tJ License. No.: Testing Company Name:�/tifi/t7l17f O Al /'�t�j� %fj r y�.__ Phone No.: _900) 66 0 Site Address: . /1 X / 3L S ,r'<II C/q- r•/SiC1 +' 305Date of Testing/Servicing: -ILI_7_/X)2, Page 1 of 3 Monitoring System Certification UXAS)l