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Feb 16 04 10:59a Fra•',!en Hill 5596'914G7 p.7 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared Cor each monitoring system.control panel by the technician who perforis the work. A copy of this forth 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 Information Facility Name: ; CCc - y LE SS Bldg. No.: Site Address: _ _ 3 yC S tyZ/lti'fk-y rW1 City: S Erk le,1/ Zip: 9 S— zlL� Facility Contact Person: �= i /44-tcf- j 51- It, Contact Phone No.: (-7e. C c} Z- e7 524 Make/Model of Monitoring System: a" 1227e 7- T«�' Ae Date of Testing/Servicing: 2 B. Inventory of Equipment Tested/Certified Check (he aeEroeriaie hoses to indicate s eciric a ul ment inspected/serviced: Tank ID:^ �� /E ;e /E Tank ID: kq In -Tank Gauging Probe. Model: _may 7 3 rl 1 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: c^ - y20 ❑ Annular Space or Vault Sensor. Model: ;3 Piping Sump / Trench Sensor(s). Model: _ 7 `/ 3 ❑ Piping Sump / Trench Sensor(s), Model: C4 Fill Sump Sensor(s), Model: 74 q - 7e -s; ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: A Electronic Line Leak Detector. Model tf ❑ Electronic Line Leak Detector. Model: ;, Tank Overfil I / High -Level Sensor. Madel: Sf�' 7 3 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). C3 Other (specify equipment t e and model in Section E on Pa e 2). Tank ID: *,a, I Tank ID: 4 In -Tank Gauging Probe. Madel: g"L- -7--3-ye"--le-9 ❑ In -Tank Gauging Probe. Model: �Q Annular Space or Vault Sensor. Model: 7 !!j41 D- q C ❑ Annular Space or Vault Sensor. Model: 4 Piping Sump/ Trench Sensor(s). Model: 7 �/ LT 3 G- ❑ Piping Sump/ Trench Sensor(s). Model: X• Fill Sump Scnsor(s). Model: )-OCK' ❑ Fill Sump Sensor(s). Model: ] Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Jai Electronic Line Leak Detector. Model:_�_ C3Electronic Line Leak Detector. Model: N( Tank Overfill / High -Level Sensor. Model:c{7 g2-4_ p Tank Overfill / High -Level Sensor. Model: J Others ecif c ui mcni t e and model in Section E on Pa e 2). ❑ Other (sgccify a ui mcnt t e and model in Section E on Page 2). Dispenser ID: ) it •2 Dispenser ID. r_ f It Dispenser Containment Sensor(s). Model: W7 Dispenser Containment Sensor(s), Model: O- ?C S Shear Valve(s). [a Shear Valve(s). J Dispenser Containment Floae s and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). ]ispenser ID: Dispenser ID: l4 Dispenser Containment Sensor(s). Model:_ 7�ry 5 Dispenser Containment Sensor(s). Model: /c 3 - J i3 Shear Valve(s). J0 Shear Valve(s). J Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). )ispenser ID: Dispenser ID: ❑ Dispenser Containment Seasor(s). Model: ] Dispenser Containment Sensor(s). Model: ] Shear Valve(s). 0 Shear Valve(s). ]Dispenser Containment Floats and Chain(s). rr.ws r_: :... _ 1 U Dispenser Containment Float(s) and Chain(s). uu •O•.1116 „u i101c ianKs or dispensers, copy oris Corm. include information for every tank and dispenser at the facility. :. 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): El System set-up Ed Alarm history report echnician Name (prilft): qy �r) (, /Jj�..,.. fi 7 Signature: 'ertifieation No.: ,- (� -� - c '/9 License. No.: esting Company Name: f i"'l F - /� Phone No.: S�' 57 SL % 7 ite Address: _ 11' 6 -' /LL 7 S/ Date of Testing/Servicing: Z / S icy Page I of 3 03/01 Ionitoring System Certification