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r? 1--or Use Br.-IllJuriscliclious 6i'ilhin Ilre,Slule )f,Cnli/i,rniu „ l tlhorily Cited: C'hapler 6.7, Hecrlllr cmcf Sufely Code; Chap er 16, Dirision 3, Title 33, Califnr•nia Cot/e of Rqulcr1inns• This form must be used to document testing and servicing of monitoring equipment. A ti n or report must be prepared for each monitorine system control panel by the technician who performs the work, o e provided to the tank system owner/operator he owner/operator must submit a copy of this form to the ocaI age r i UST systems within 30 days of test elate. CC A. General Information �& Facility Name: HEA,cKEE q 4e 0!�C yf cf, f,)/}h'i►'aJ'f�r f Site.Address: Clon 43, LPA NE City: Lez r_-,tPL`14 7 Facility Contact Person: b i b A Contact Phone No.: ( Z0,7 Make/Model of Monitoring System: G lLhF—i 'L-. i�rOh"T i�j—3C-CDate of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific et ui ment ins ected/serviced: Tank ID: 3_ Qf.___T Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 4 Annular Space or Vault Sensor. Model: Z AL Annular Space or Vault Sensor. Model:_ 0 Piping Sump/Trench Sensor(s). Model: 20 J ®(Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model:_ III Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui merit type and model in Section E on Page 2), ❑ Other(specify e ui.merit type and model in Section E on Page 2). Tank ID: I .00A Tank ID: '�► `_ T""1' -` "o"' ' Model: ❑ In-Tank Gauging Probe. Model: ( Annular Space or Vault Sensor. Model: ANS€ TANK—T— 4 Annular Space or Vault Sensor. Model:_'_ RM -� Piping Sump/Trench Sensor(s). Model: LOE) A Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: OL Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. . Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui merit�d model in Section E on Page 2). ❑ Other(specify equipment ty a and model in Section E on Page 2). Dispenser ID: 1 1-2- Dispenser 1 D: "7 ,f �3 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contaim hent Sensor(s). Model: JaQ Shear Valve(s). ISP Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). A Dis enser Containment Float(s)and Chain(s). Dispenser ID: 34-+ Dispenser ID: 9,# i U t�.i E�� r✓ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: j Shear Valve(s). A( Shear Valve(s). !� Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 64-10 Dispenser 1D:_ Q 31PYTEA 7riz: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �1 Shear Valve(s). 4 Shear Valve(s). 1d Dispenser Containment Float(s)and Chain(s). Ok Dispenser Containment Float(s)and Chain(s), *Ifthe facility contains more tanks or dispensers,copy this form. l nclude information for every tank and dispenser at the facility. C. Certification - 1 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 generatingh reports,l have also attached a copy of/the report;(check all that apply): El Sy t-u arm history report JOA Name Technician Nae(print):�N � i'�V r,,Cn Signature: Certification No.: /�y?3 ��'Ce W 54 33 ,7 —UT License.No.:�}n-L '� ©� ' 17z� Testing Company Name: QC Site Address: 700 �. CWEe,0146E AAA(ff Date of Testing/Servicing: 10/16 / :' '� Monitoring System Certification Page 1 of 3 03/01 A Results of Testing/Servicing 1511 C