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l WUyc 6p.-Ill./urisdiclions It'ilhin Ilrc.S�cile n/'('all urniu • Aulhorily CitedChaplcr 6.7, Hen/Ih and Sclk/V Code; Chapter 16, Division 3, Tile 23, California Code of 2aguhnio11e This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control pane( by the technician who performs the work, A copy of this form must be provided to n the tank system owner/operator. Theowner/operator must submit a copy of this form to the local agency regt!!Sting UST systems within 30 days of test date. A. General Information Facility Name: a I-ASAS #%/ D Bldg.No.: Site Address: IdfJ,r- W. /j/ fes^ City: SfOGC i17 Zip: 93'l12- Facility Contact Person: ff^2— Contact Phone No.:(ZD/` ) Make Model of Monitoring System: A)J) Sj j k— Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the orimouriate boxes to indicates eciric ed ui meat ins ected/sewiced: Trnit ID: Ts nit ID: )Q, DC7 In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: LS-3 A ❑ Annular Space or Vault Sensor. Mode(: J Piping pSensorls). Sensor(s). Model: LS-3A Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensonjs). Model: Fill Sump Sensor(s). Model: 2d Mechanical Line Leak Detector. Model: Px-1 V Mechanical Line Leak Detector. Model: FX-/V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: - ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s cify equipment tye and model in Section E on Page 2). ❑ Other(s eci a ui nient a and model in Section Eon Pa a 2). T•nk ID: T:nit ED: In-Tank Gauging Pro be. Model: �In-Tank Gauging Probe. Model: fe�Annular Space or Vault Sensor. Model: LS'3q ❑ Annular Space or Vault Sensor. Model: �I Piping Sump/Trench Sensor(s). Model: LS-3 N Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Mode(: FX - 1 V Mechanical Line Leak Detector. Model: 997 v� 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Took Overfill/High-Level Sensor. Mode(: ❑ Other(s eci equipment tye and model in Section E on Page 2). ❑ Other(specifya ni meat ty a and model in Section E on Pa a 2). Dispenser►D: / ' Dispenser ID; ❑ Dispenser Containment Sensor(s). Mode(: ❑ Dispenser Contaiimnent Sensor(s). Model: Shear serCValveContainment — Shear Valve(s). Dis censer Containment Floats)and Chain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: �"Y Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear serC s). Shear Valve(s). Dispenser Containment Float(s)and Cbain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID:_I en ❑ Dispenser Containment Sensor(s). Mo El Dispenser C'ontai nt Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containnnent Float(s)and C ain(s). ❑ Dis enser Containment Floats)and Chain(s). "If the facility contains more[milts or.dispensers,copy this form. Include information far every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced 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;(check all that apply): 0 Sy i9 Alarm history report Technician Name(print):� __�� Signature: Certification No.: //93 C 52(33a ^UT' License.No.: /gam-j .#q - _. . .Testing Company Name: -.__._._.,._.-�....._... Phone No.:(Sjp�)2'SW_,__6 .2. Site Address: 1 Oalb (1, Iwt+l'da 99 Date of Testing/Servicing: / //n / 06 Page I of Monitoring System Certification 03/01 D. Results of Testing/Servicing