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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California , ,' ` i `• . HEALTH Authority Cited.Chapter.6.7,Health and Safety Code;Chapter 16,Division 3, Tide 23, California Code of RegulatioiWt This form must be used to document testing and servicing of monitoring equipment. A enaiale cemA a u d for each monitoringsystemcontrol panel by rhe technician who performs the work. A copy of this intro must vide m 'e system owner/operator. The owner/operator must.submit a copy of this form to the local agency regulating UST systems within :0 days of test date. A. General Information Facility Name: 5-0fr /74_ 34 i Bldg.No.:!_ Site Address: 92 1 /� 1141 ST 6^7 t%� City:_ 1,1A,41 T cot Zip: Facility Contact Person; 4: e U r 1 Contact Phone No.:(_) Make/Model of Monitoring System: (i r L�c i c a ft's L' Dare of Tesung/Serviciug: L0Jj3/2Q B. Inventory of Equipment Tested/Certifled Check thea ro bate bora to indicate c equipment fm serviced: Tank M: C r Tank 1D: Z /'14 0 0 1'_Tank Gauging Probe. Model: T':+ok Gauging Probe. Model: UKtandaz Space or Vault Sensor. Model:4f e'4 Annular Space or Vault Sensor. Model: C3 Piping Sump/Trench Sensor(s). Model: L�Ag fj' S'i 74100--c:: 2,Nuag Sump/Trench Sensor(s). Model:4102S520041L e 7 ❑ Fill Sump Sensor(s). Model ❑ Eill Sump sensor(s). . Model: C.Yi:9echanicai Line Leak Detector. Model: Z 00: - "echaracal Line Leak Detector. Model• e L ?000 13 Electronic Line Irak Detector. Model: U Electronic Line Ieak Detector. Model: ❑ Tank Overfill/High-Level Senator- Model ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment FM and model in Section E on Paw 2). ❑ Other(specify equipment type and model in Section E on Page 2). R-A,Pui* Tank ID: TankMadel• ClIn-Tank Gauging Probe. Model: az Space or Vault SensorModel: O2S '/ H 4Gc• D Annular Space or Vault Sensor. Model: rag Sump/Trench Sensor(s). Model:1 J1#d 2 PU C00 C Cl Piping Sump/Trench Sensor(s). Model ❑ Fih Sump 8ensor(s). Model: ❑ Fill Sump Sensor(s). Model: mechanical Lue:Leak Detector Model: Q2 :2 e)t:;c ❑ .Mechanical Lou:Leak Detector. Model-. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector- Model: Q Tank Overfill/High-Level Sensor. Model' 0 Tank Overfill/High-Level Sensor. Model O Other(specify migment and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Pa a 2). Dispenser In. Z Dispenser to: ❑ Dispenser Containment Sensor(s). Model: C7 ❑ Dispenser Containment Sensor(s). Model: e?AQ 211z'S-3 at. ❑ Shear Valvc(s). ❑ Shear Valve(s). a DisgqsE Comammeat Floats)and Chain(sL el Dis ser Conmfnment Floa[(s)and Chain(s). Disperser ID: S'At 6' Dlspenver ID: Q ❑ Dispenser Containment Senst r(s). Model: 1'14e�zAL p Dispenser Containment Sensor(s). Madel: u3S-/-J<c' ❑ Shear Valve(s). ❑ Shear Valve(s). O Dispenser Containment Floar(s)and Chain(&). ❑ Dispemper Containment Floar(s)and Chain(s). Dispenser.ID: Disperu at:ID: ❑ Dispenser Containmcm Sensor(s). Model ❑ Dispenser Containment Seasons). Model: ❑ Shear Valve(s). U Shear Valve(s). L]Dispcn=Containment Floags)and Chain(a). ❑ Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Iachtde information for every tank and dispense az the Facility. C. Certification-I certify that the equipment identified in this document was inspeeted1ser+iaed in aeeoFdaeee with the;nmurarturies' guideffces 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 repot' ,,f ek :/1'o pP(Y): ❑System set-up ❑ Al to putt Technician Name(print): t-ci 7 %lint i Signature: _. Certification No.: .) 2 y License.No.: jD Testing Company Name: C //I�j"1�/o'ti U IV y A 11'{ 7e s ti �t i Phone No.:( 941 c ) E t.7 Cl—9 4"f S Site Address: 26- 13 0'>, I G 5'Gr A C r C P eV"3-?C' `(Date of TesdnglServicing: Page 1 of 3 93101 Monitoring System CertilLeation