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MONITORING SYSTEM CERTIFICATfON For Use By All Turlsdlcdons Wlthln the Stare of CalVormia Authority Cite& Clurple'r6.7,Health and Safety Code;Chapter 16,Divtslon 3, Mle 23, California Code of Regulations This form telae[be used to document testing and servicing of monitoring eguipmalat 'Sm Ar fi l'or Each monitoring systcliCOittrQl ague by the"hnician who performs the.wort ,A,copy of this tbrm taut be.provided to tb-,tank ::)'stern ovmtrloptrator. T•ne owllorloperator must cuhtnit a copy of this form to tbo local agency regulating CJST systems within 30 [lays of test date. A. General Information Facility Nnmo: __ AfWxr�'4 C/S /Z5 Bldg,No.: Site Address: /'JY7lJ /i�fJ�/��. City: Zip- gS. .36 Facility Coaltact Person: Contact Phone No.:(" N4Qkellvlodel of Moaitoting System: Ery�J�/z oc7r Date of Tcstiag/Serviting; B. Inventory of Equipment Tested/Certiried Chock th't appmPrbae boxes to UAcam spedfle equipirnent lnstxctcdfserticGd: Tank ib: (IN&4599 F� I Tank ID; 29F,l�L_ . A In-Tank Gauging Probe. Model:keall, fo-) I M In Tank Getiging t'robe. Modclt r- 9 AnnulnrSpaceorVauhScnsor. Model: 2AS(39�t/Z.b a Annular8paccorVnultsenmr. MM Jt ? Fs• M Pipiag Sump lTmach Scmor(s), Model, 2 Piping Sump ITrench Sansor(s): Modct; Za S th9- 0 Fill Sump Sr sor(s). ModcL•_ 3 Q Fdt Sump senors). Modcl:��/y� p•.Z�� ❑MrthanlcrJLlnoLea1 i)otocUor. ModcL• ❑ Model: 2 Elccuonic'Lino Uuk Detector. Model: -da 2t Blec tmnic Unc UA Dete=r. Model: fit Tank Ovrrm I High-level Sensor, Modal' 43 Tame OverCilJ I High-Level Scusor. Modol;- ig 13 Othfr I(specify oquiEwnttypcand modal in Section E on Page 2). . . q Outer s x Iptnent and model In Seeden B an Pa c 2). 'Cant:ID' 'ratnk ID, t>d In-Taut;C*-uging Prole. Model: 401 ❑Ia-Tatd CA4ng Probe. Model:. _ 61 Annular Space or Vault Sensor. Model: A Annular Spaec.or Vault Sensor, Modol._.. 0 Piping Sump/Trench Sensor(s). ModcL 441D'• O 0 Plping Sump 1 Ttar,ch Sensor(s). Model: T R Fill Sump Seasons). - Model: O• o ID Fill Sump som*p). Modol: ❑ Mechanical Lyne T= rktcctor. Model: U Mechanical Linc Leak Detecmr. Model: WBlectroaicL.intLeakDetector• ucsdol: Cl FleettonitLineLealcbetector. Madel; jp Tank Overfill I High-Lave]sensor. Model:e,4k6ja ❑7)tair Ov=AU I High- vol Sensor. Model: O Othcr(..p=ify�2u mmt typo And model in Soudan 8 on Pfl o 2}, ❑ Other(iliccify egui meat typt and model in Section&on pago 2): r)I stSerTOc DL, erID: 1�bispcnetr Conminm:nt Sensoris). Madel• 3 Dlspenser Containmml Seosot(5). Madel: o^ Z ShearVtdve(s). C!ShearValve(s). Q Dispenser Containment Floi0s)and,Chalu(s), d I)iv seTContalttmentFlont(s).andChains). Dispenser ID: Dispenser YD: J� Dispenser Coptaiume tt Settsor(s), jr Modcl: Ila Dlspc=r Containment 3enmr(s). Modch O Id Shear Valve(s). .8 Shearvilve(s). ❑T)isponscr ContninmcntFIoat s)and Chnin(s). ❑V Dispenor ContaininmtFloat(c)and Chaia(s). Dispenser M; 131spcn5er ED; z �Dispcnscr Conrainmcnt Scnsor(s), Jvfodcl: f$Dispenser Cohtainmcnt Scnsar(s). lrfedel: D t4 Shear valve(s). GI ShcAr Valvc(s). L1r)irpcn=r ContalntrimE Float(s)and Chain(s), t]Dls nsar ConcninmcntFlaat(s)and Chain(a). -If the facUny contains=re tanks or dispensers,copy chis form Include infotmatien Ear every tank end dispenser at tho facility, C. Certification-Icertiiy that tha equipment identified invthis,documentwas lrLspeetedlsemiced M rascardarP,.with themanufactitren guidellnes. A.tlAthed to this Cer(lilcatlon is information (e g.manufacturers' checklists) necessary to verily that this informnGou is correct and a plot plan showing tho layout oI monitoring equipment, for any equlpuwnt�apab)e of generating such reports,-1 have also attached a copy of the re t t (clreaL all than ap l I}; I system set-up t hishorp report - Technician Name(Pr�nt)� N Slgnatura C'ertlficution l la,; A239 15 h License, o.: LL' Testing Company Nam': 4J91Wc ~ PhoneNo,! Site Address TV �. X5110 7 pate ofTesting/Scrricutg: i�/c 0/ q Page tof3 o3lG:. NIOnitoring System Cerfi i ltlon