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Feb 14 03 03:48p F nzen Hill 55 881467 p.3 MONIr . RING SYSTEM CERT. TION For Use Authority Cited: Chapter 6.7, Health and y All h SafetyCode„1lChapteons tr/r16,in i1Drvision ,tte of Title 23t 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 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 Information Facility Name: bb0 �-e $ 5 r Bldg. No.: Site Address: 0 �; 1'1/1 -At �i-k+E rct. ~ t Person: City: -CCTe,.Zip: �'t SFacility Conta1 Zed Contact Phone No.: ( ) g gZ p e 2 • Make/Model of Monitoring System: 1f -r-, o5?{,er I�AZ T TG S - 3 5C) Date of Testing/Servicing: ! / /6 /D3 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates eciCe a u1 meni ins ected/serviccd: Tank ID: UN .g 4D r N ® In -Tank Gauging Probe. Model: S `' Z '39 -111 Tank ID: ❑ In -Tank Gauging Probe, Annular Space or Vault Sensor. Model: _7F -1f jv 0 -y?_6 CX Piping Sump / Trench Sensor(s). Model: Model: ❑ Annular Space or Vault Sensor, Model: 7yY3SSo -ZDV M -Fill Sump Sensor(s). Model: -ZO 0 Piping Sump /Trench Sensor(s). Model: 1_gy 3W $ O Mechanical Line Leak Detector. Model: J, Electronic Line Leak Detector. ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model; Model: eF '5f Tank Overfill / High -Level Sensor. Model: r p(042t_ -7,es-3 5D D Electronic Line Leak Detector. Model: O Tank Overfill I High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2) ❑ Others (specify a ui ment type and model in Section E on Pap 2 Tank ID: re”, tUw� ka In -Tank Gauging Probe. Model: 7j�c(7"3p'o_ry / . Tank ID: ❑ In -Tank Gauging Probe. Model: _ 4 Annular Space or Vault Sensor. Model: 7tSf3 -r-ZZ _ 0 Piping Sump / Trench Sensor(s). Model: ❑ Annular Space or Vault Sensor. Model: ��, g Fill Sump Sensor(s). Model: DRQ ❑ Piping Sump / Trench Sensor(s). Model: _l95F -Z0— ❑ Mechanical Line Leak Detector. Model: _ 0 Electronic Line Leak Detector. ❑ Fill Sump Sensor(s), Model: O Mechanical Line Leak Detector. Modes: Model:�_ 9 Tank Overfill /High -Leve[ Sensor. Model: robe Te$�-35r ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. 2-0 —,1 (s ecif a ui meat t e and model in Section E on Pa2c 2). Model: ❑ Other (s ecif equipment t e and model in Section E on Pa2). Dispenser ID: / Z if Dispenser Containment Sensor(s). Model: 3 (5-05 5 -Shcar Valve(s). Se Dispenser ID: JM Dispenser Containment Sensor(s), Model: Q - D Dispenser Containment Floats and Chain(s). U Shear Valve(s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID; 7> ---JE-t 0, Dispenser Containment Sensor(s). Model: Try cf 3fC_2e K Dispenser ID: il Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: D Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(s), ❑ Dispenser Containment Float(s) and Chain(s). )ispenser ID: 11 Dispenser Containment Sensor(s). Model: Dispenser ID: - d Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ]Dispenser Containment Floats and Chain(s), ,If ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). the facility contains more tanks or dispensers, copy this form, 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 re ort; (check all that apply): System echnician Name (print): p tp �1Q, set-up J9 larrrt i ory re art T; Signature: 41 ,ertification No.: 2�7 2- $ ((a _ License. No.: esting Company Name: FfAIJ Z e I Phone No.:( ite Address: J S f / V �Cc ere Ct 32-7q Date of Testing/Servicing: I 1 /6163 Page 1 of 3 03/01 lonitoring System Certification