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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Ciled: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Lode ofRegulationa 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 Mel by the technician who performs the work. A copy of this form most be provided to the tank system owner/operator. The owner/operator must submit a copy of this from to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name:%rAcy c 4 c v l.., Bldg.No.: Site Address: 3 77 S T124c y 731w.) City: TrZA c % Zip: `j 3 7.6 Facility Contact Person: r- "[ Contact Phone No.: (Lo 9 ) 63 6 — 9 V Z Z Make/Model of Monitoring System: IJtc fes, (L4a t 7-L S- 31-0 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate bosea to indicate specific equipment inspected/serviced: Tank ID: ReQ W / ' Tank to: Dlesa i. ❑In-Tank Gauging Mobc. Model: Mq-i„_- /a^a bt ❑In-Tank Gauging Probe. Model Mss /fro tip Annular Space or Vault Sensor. Model: yO 9 6(]Annular Space or Vault Sensor. Model: y0 9 ®Piping Sump/Trench Sensor(s). Model: j(3 S Piping Sump/"french Sensor(s). Malec Z0 b Fill Sump Seasons). Model: 7 0A Fill Sump Sensor(s), Model LU g ❑Mechanical Line Leak Detector. Model: ❑Mechanical Linc Irak Detector. Madel. Electronic Line Leak Detector Model: fJ y Y Electronic Line Leak Detector. Model. ,111 fl y ❑Tank Overfill/High-Level Sensor. Malec: ❑Tank Overfill/Iligh-Level Scasor. Madel ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: swnn. L TankiD: ❑In-Tank Gauging Probe. Model: i t,7 tie E]to-Tank Gauging Probe. Model. (_7}Amudar Space or Vault Sensor. Model: 1101 ❑Annular Space or Vault Sensor. Model. ®Piping Sump/Trench Senso(s). Model: 7-08 E]Piping Sump/Trench Senser(s). Model 0 Fill Sump Senser(s). Model: 7a1Ci ❑Fill Sump Sensogs). Model: ❑Mechanical Lim Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 6 ti 9 y ❑Electronic Line Leak Detector. Model. Tank Overfill/Hr Levcl Sensor. Maley. ❑Tank Over /High-Level Sensor. Madel: E] Y>H ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify egmpment type and model in Section F:on Page 2). Dispenser ID: 1 — 7 Dispenser to: 7 — 8 ` [&DispenserConmimnco1Sen5nr(s). Model: 7,014 Dispense ContainmentSensor(s). Madel: 206Shcar Valve(s). — y Shear Valve(s). ❑Dispenser Containment Float(s)and Ctuun(s). [I Dispenser Containment Floats)and Chain(s). rDr��isspenser ID: _ ti _ Dispenser I D: cl—3 0 Dispemer Cornamment Sensor(s). Model: ZCA ®Dispenser Containment Sensot(s). Madel ZOS 1X '.1+'!. Shear Valve(s). I�Shear Valve(s). t, ❑Depanv Containment Floats)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser D7: S— Dispenser to: �% 7- ®Dispemtt Containment Sensor(s). Model: 0 I�.Dispenscr Containment Scnsor(s). Madel: Z 0 (j %shear Valve(s). [�Slmar Valvc(s). D'upmnc Containment Flon(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). *If the fhcitity contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. CerfiflCAtion - I certify that the equipment identified in this document was inspected/serviced in accordance with the maaafaehrrers' guidelines Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have aha attached a copy of the report;(check all that app[}): [4 Sysset-up ® Alarm history report Technician Name(print): 51 E U E So u v Signature: Cerdficati/mNo.: N 0 Z u 3 License.No.: Testing Cpntpeny Name: MVP /fit 7( 1r• Eyed LNt _ Phone No.:(11-4 ) 95 Y— /S 3 TeWng Comitany Address: P p /3itA p 8/ /=p14, C4 Is,-76,1 Date of Testing/Servicing: Page 1 of 4 www.aaidoeaorlt Rev.01+17N8 3.