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81/02/1995 03:27 2097546722 CALAVERAS EW HEALTH PAGE 01 MONITORING SYSTEM CERTIFICATION Fw ! s. hn:c c:criorrs Ka. Aulhoriry Cited: Chapter 6.7. Health and Sajery Code: Chapter 16. Division 3. Tide 23. California Code r -rg�r�nons This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a Scnaaate certification !2K re mll must pG vrevared for each monitoring systemcoulroj panel by the teehnieian who performs the work. A copy of this form must be provided to the tank system owncrloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. instructions arc printed on the back of this page. A. General Information Faetlity Nance: Bldg. No.: cit. Adrinrcc, f" L i f) CCZ_�� l /c City . (✓{ �� zip: Feci)ity Contact Person: r U Contact Phonc No.: -�wo— // C Z.. Z_ MakelMotdel of Monitoring System: r d k."rL TLS -3' 1 `L! `I �7J �L"' -Date of TesanglServicing:�J�/f v / t} S. Inventory of Equipment Testrd/Certmed — . — L--- .–A. Alt *a &4nn ainma"r Inenw tpelfc cvlrtod- Tank ID: '1 S v Tank m• 3 C In -Tank Gauging Pro M 1: k1 In -Tank Gauging Piobc. Model: qk-7mnular Spaet of Vault Sensor. Model: %' ' t:� - t:' .l2' Annular Space or Vault Sensor. Model• R Piping S-Wrrrateh Senaor(s}. Model: Iy - ca ping Sump/Trench Sensor(s). Model: -2- 0 Fill Sunp Sens;m(s). Model: f i / - ' id'fitl St+tnA Scnwr(s)- O Meehuueal Linc teak Detector. Model: Q Meehanicnl Linc Leak Detector. Model: ❑ Electronic Lite Leak Detector. Model: 0 Electronic Line Leak Detector. Model D Tank Overfill / High -Level Sensor. Model: t)7'el4 3.t%- 0 Tank Ova&It t High -Level Sensor. a Dispenser Containment Sensor(s). Model: Model. C4`!i1 �� ?L 4-- O Dispenser Containtrwnt Sensor(s). Model: 0 Shear valve(a). 0 Shear Valtrc(r.). O Dispenser Containment Flost(s) and Chain(0, 0 Dispenser Containment Float(s) and Chain(s). O Otho ts_p5cify equipment ryge and model in Section E on Pu •c 7)_ Q Other (specify c ui mcnt type and model in Section E on Pace 2). Tani ID: 1'7- 4 Vi1 4j L c Teak ID: C@ In -Tank Gauging Probe, Model: Q 1: a In -Tank Gauging Probe. Annular Space or vault Sensor. Model= Annular Space or Vault Sensor. Model: �� - 2'Piping Sumprrrench Senuor(s). Model: t " -2U' 2-riping SumtptTrcnch Sensor(s). Model 1 t jMll Sump Sensor(:). ModcI: 7 c y Mill Sump Sensor(s). Model: 4"- 0 Mechanical Line Leak Detector. Modcl: 0 Mcchantcal Line Leak Detector. Model: Q Electrontc Lime Leak Detector. Model 0 Electronic Line Leak Detector- Model: Q Tank Overfill / High -Level Senior. Model: Cl Tank Overfill / Nigh -Level Sensor. Model: Dispenser Containment SensotCs)- Mudd: ! rt`%i 3 St Zu FM' 121 Dispenser Containrnent Sensor(s). �Z Q shear Valve($). a Shear valvc(s)- Dispenser Conti3nntcat Flost(s) and Chain(s). D Dispenser Containment Float(s) and Chain(s). 0 Other fspaifX egut t turd model in Section E on Page 2). 0 Other c ui rncnt and rnodd in Section E on Pae 21• C. CertifiCatfon - I certify that the equipment identified In this document was inspecteellserviced in accordance with the msnufacturers' gaidelities. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this infonnstlon is correct and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of she (cheer all that apply): et -up report; t�,�4 i)Ist"V report. Technician Name (print): 5 1.1S`Gcrt./Lic. No.: __ Signature: _ Uf =' ' Testing Company Na=. l G?J 7e (�J4S L:�_ Phone No.: �. G ' �• CAILM-41 post -It' Fax We 7671 a 3 of 1P paged T.T. on ar s c0.1136va EZC&cu. Ptior- • '441— [,3-f2_ Pnane • 'rS10 T'd ZbE9-19t, (600) umoug aiu.te0 e86:01 60 IT umC