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19255517888 Main Fax • GETTLER RYAN INC 121 a.m. 02-16-2007 2/8 s e . MONITORING SYSTEM CERTIFICATION (�n For Use by All Jurisdictions Within the State of California p� f I Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cali ornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pre^aeed for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank 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 Informaatio # SLo O Facility Name: Bldg.No.: Site Address: -0 A ), W i S or, Eck", City: 9+OCAL f.� Zip: 5 ZO Facility Contact Person: Contact Phone No.: L--) Make/Model of Monitoring System: Vtew Rno+ TL S 3 Sy Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: -T 2. , 8 S M i —Cfe- Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. e ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor Madel: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Cl Mechanical Lin ak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electron a Leak Detector. Model: Cl Tank Over lI/High-Level Sensor. Model: ❑ T erfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). they(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Mod O In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor./l odcl: ❑ Annular Space or Vauit Sensor. Mo ❑ Piping Sump/Trench Sen (� Model: ❑ Piping Sump/Trench Sensor(s. odel: ❑ Fill Sump Sensors Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical ' Detector. Model: ❑ Mechanical Lin Detector. Model: ❑ Elec ine Leak Detector. Model: ❑ Electron' ne Leak Detector. Model: ❑ Overfill/High-Level Sensor. Model: ❑ verfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). LI Shear Valve(s). 13 Dispenser Containment Float(s)and Chains ❑ Dispenser Containment Float(s)and C s. Dispenser ID: Dispenser ID: ❑ Dispenser Contai=Float(s) Model: ❑ Dispenser Containment sor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser CorralChain(s). ❑ Dispenser inment Floats)and Chain(s). LDispenser ID: Dispens spes Containment Sensor(s). Model: ❑ penser Containment Sensor(s). Model: r Valve(s). Shear Valve(s). penser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,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 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 equs ment capable of generating such reports,I have also attached a copy of the report;(che k all that apply): �vS ystem up Alarm lystyry report Ck l Technician Name(print): C7�a d.EGre �c� Signatu`A:� i(Lx 1. 13 Certification No.: A 3013 5' License.No.: Z Z 0 4S'3 Testing Company Name: L'T e[//ef- l`y a•. fin C Phone No.:(!?Zj ) -5-51—�'•�SS` Date of Testing/Servicing; 2 O Site Address: Page 1 of 3 03/01