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MOARING SYSTEM CERTMRTION Authority Cited, Caaptsrb.7" Health and SaletvuCodec,�dl-. Witiun the State of California f Chapter I6, Division 3 Tit 23 • e , CaG.70m Code ofkegulatons This form must be used to docutttent testing and servicing of monitoring equipment. A separate certification or re or�Within furfur each monitoring system control panel by the technician who performs the work A copy of this form must be pr system owner/operator. The owner/eperator must submit a copy of this form to the local agency regulating UST`--"_ days of test date. Fa General Information AUG 2 5 2003 Facility Name: �'%tN1ES �y;� Site Address: _ 5�'�p 7Bldg. No.EUV2 )A Fr t t<l7€Q / city: �?oc kTa � �W_N .T HEALTF Facility Contact Person: CA Zip: / WRACES Make/Model of MonitoringSystem: _ Q&3R2« cContact Phone No.: (_) irc ------ B. Inventory of Equipment Tested/Certified Date of Testing/Servicing: Tank ID: J LC N 9"I�Tauk Gauging probe. ta'AynWar Space m Vault Sensor. Cd'1'iping Sump / Treach Smsor(s). Cl Fill Sump Sensor(s). Orglmhaoical Line Leak D t ctor. 0 Electronic Line Leak Detector. 0 Tank Overfill i High -Level Senso,. 0 Other (s a tri [Hent t e and Trra�n/k,ID: 2 _ S'c( 6QX60 Q Tank Gauging probe. Annular Space or Vault Scasor. O -Piping Sump / Trench Semor(s). Frjl Sump Sensor('). Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. ❑ Tank Overfil) / High -Level Sensor. Model: Model: Model: Model: Model: Model: --�- Model: __tAA G -9-- Model: WW. � a oae� Model: 1Qj opld Model: Model: _STP -- Model: _ Model: Dispenser ID- / - Z 0 Dispenser Coumiument Sensor(s). Model: 3-Sliear Valve(s). Dispenser ID- -3- 0 -0 Dispenser Containment Sensor(s). Model- Gd-Zcar Valve(s). Dispenser ID; S {o 0 Dispenser Conmmmem Sensor(,). Model: ear vJve(s). _ •spencer Conrainmen[Floa[(s)and Chain(') If the facdtty contains more tanks or dispensers, copy Ta4 ID: 3- A__ tt`--�_ 2 -In -Tank Gauging Pmhe. a'"ular Space or Vault Sensor. 0 Piping Sump/ Trench Sensor('). 0 Fi11 Sump Sensor('). Q -Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. 0 Tank Overfill / High -Level Sensor, TanklD 0 In -Tank Ceug-g Probe. 13 Anular Space or Vault Sensor. 0 Piping Sump/ Trench Sensor(,). 0 Fill Sump Sensor(s). 0 Mechanical Line Leak Detector. 0 Electronic Line Leak Detector. 0 Tank Overfill / High -Level Season ❑ Other tsnw.;fi, .,...:.,..._-"-- - ' Dispenser W_ - 0 D:0 Dispenser Containment Semor(s). a -`Shear Valve(s). Amnn Containment Float(s) and Dispenser ID: _ Y —Cz penser Containment Sensor(,). Dispenser in, 0 Dispenser Containment Sensor(,). 0 ShearValve(c). Model: Pi9D3S90 r,x,.... Model: , nffgw�77<4 0_.__,,_, •r. Model: Modei: ir{C Madel: Madel: -- Model: Madel: Model: Model: Model: Model: 011 ---- � luuu uuurmauon 'Of every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspeeted/servieed in seeordanee with the manufacturers' guidelines. Attached to this Certification is information (eg, manufacturers' checklists) necessary to verily 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; (check all that apply): (�3Vstem set-up Technician Name (print): AL v t N L ir-t iCBuR - p � fo��pooi.,, Signature: ft--r� �d�ll-moi i Certification No.: - License. No.: VD n'?o Testing Company Name: C'.119<u�iN�J ,Q�r/StbA� fii5'tt �-M9r/ Td� / CC Phone NoJ gcA) Geo - 9� Site Address: c=p 7_ L , 04422E , (� 6 91) ST6 C,<ntj C�.S� Dale of Testing/Servicing: -L4- 11 / 6� Monitoring System Certification Page 1 of 3 03f01