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1ECUV D MON.,�ORING SYSTEM CERT IFb..ATION For Use&&.Jurisdiction 14711in the Sla/e gf'Califbrniu JUL 13 21107 Authority Cited. Chapter G.7, Heallh and&!/ely Code; Chapter/6; Division 3, Tille 23, California Cotle of Regulario�zs This form must be used to document testing and servicing of monitoring equipment. A separate certi tca�IR`lr �°�ci� t HEALTH Ic e prepared for each monitoring system control panel by the technician who performs the work. A copy of this form miist�6e provi ed to tjWtank 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 Information Facility Name: J t L 409&lr7- Bldg.No.: Site Address: a( is 0. bels. O 'sT City: 7C,-- --cot-'t& Zip:_9.53 Facility Contact Person: Contact Phone No.:( 20'? ) ?Az— Make/Model of Monitoring System: D�✓/ O7 7(5-3�L� Date of Testing/Servicing: 5 /3/ /O7- S. Inventory of Equipment Tested/Certified Check the a pro u•iate boxes to indicate specific er ui spent inspected/serviced: Tank ID: EN7 Oc-"f Tank ID: 9 ( cc--r A In-Tank Gauging Probe. Model: A1,46? t A In-Tank Gauging Probe. Model A-dr 21 Annular Space or Vault Sensor. Model: O A Annular Space or Vault Sensor. Model: Zp 8-Piping Sump/Trench Sensor(s). Model: 20 B A-Piping Sump/Trench Sensor(s). Model: ?� ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX-/ XMechanical Line Leak Detector. Model:LpZo eo ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). T, nk ID: Tank ID: nE ❑ In-Tank Gauging Probe. Model: x A In-Tank-Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 1,Piping Sump/Trench Sensor(s). Model: Zpg ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: J-Mechanical Line Leak Detector. Model: LZPZodp ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: rAJ, Other(specify e ui ment type and model in S tion E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). penser 1D: ( 't Z Dispenser ID: Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). At Shear Valve(s). is enser Containment Float(s)and Chain(s). 18L Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 Dispenser ID: 1 t S ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: -- AShear Valve(s). AShear Valve(s). Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser 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 equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): Syslet-u larm history report Technician Name(print):�� w; Signature: CCS +W 52 ;33x.1 07- Certification No.: License.No.: 1 4 ,/4P7lo Testing Company Name:--A&1't�r4 _ ��-r Phone No.:(109 )'71 Site Address: ELjjo-e-A be S-( Date of Testis Servicin � g: 5- /3t /OT o Page I of 03/01 Monitoring System Certification D. Results of Testing/Servicing W�