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C VE D For Use f3r!.411J111'iR1 CllUnS 101hin the Skrle ofC'nlifbrnicl cep p Authority C'ilecl: Chapter G.7, l-lectllh nnel Su%{t�Code; Chapter l G, Dirision 3, Title 33, CuliijbI- W04 J�h�gNk�nQ tliuns This form must be used to document testing and servicing of monitoring equipment. A se ariPVbR�MMFiIVToHrust be prepared for each monitoring system control panel by the technician who performs the work. A copyff� ${7� t•ovidecl t- the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: �72 `5'/�L L(_ Bldg.No.: Site Address: 3�?ao /1-1oA�!r=L'9g'j 0 sr. City: (Y=iX&7-p, ) Zip: Facility Contact Person: A^,1 Contact Phone No.:(Q O )SSZ - 1/9 2 Z Make/Model of Monitoring System: ",We- T - 'r[s-M60 Date of Testing/Servicing: 9 / /( / OA B. Inventory of Equipment Tested/Certified Check the a i ro mate boxes to indicatespecific cc ui nient ins ected/serviced: Tayk ID: Tank ID: Z)/ C55 [=L ®'Jn-Tank Gauging Probe. Model: M ACh 1 C�Jn-Tank Gauging Probe. Model: MA& I 5r,Annular Space or Vault Sensor. Model: SOL 6Annular Space or Vault Sensor. Model: 3pZ &f iping Sump/Trench Sensor(s). Model: ?p8 ei aping Sump/Trench Sensor(s). Model: 208 CrT Fill Sump Sensor(s). Model: Z+�B b7 Fill Sump Sensor(s). Model: Zcl$ ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: I�Electronic Line Leak Detector. Model: P L-L-0b EfElectronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Page 2). El Other(specify equipment ty e and model in Section E on Page 2). Tank ID: Tank ID: ICY ❑ In-Tank Gauging Probe. Model: C�1n-Tank Gauging Probe. Model: !�)rl G 1 ❑ Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: �iping Sump/Trench Sensor(s). Model: ZOO ❑ Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: zcCA ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. - Model: Electronic Line Leak Detector. Model: P L%_0 ❑ 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 e ui anent type and model in Section E on Page 2). Dispenser ID:6t 7` Z Dispenser ID; �7F & ;Rf Dispenser ment Sensor(s). Model: 2-6 y;Dispenser Containment Sensor(s). Model: 10 ®-Shear ValvAN-Shear Valve(s). ❑ Disienser ment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 7� Dispenser ID: .gKispenser Containment Sensor(s). Model: 21��— Er-Dispenser Containment Sensor(s). Model: O RL Shear Valve(s). ar-Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser I D: ❑ Dispenser Containment Sens Model: ❑ Dispenser Containment Sensor(s). del: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floa s)and hain(s). ❑ Dis enser Containment Floats) d Chain s). 4 If the facility contains more tanks or dispensers,copy this form. Include information for every tante 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 eq iTi pent. For any equipment capable of generating such reports,I have.also attached a copy ofthe report;(check al/that apply): CI System t- p narm history report Technician Name(print):—�91V p-LV�1„,C� Signature: Certification No.: C W to J3a7 -U T Certi ��3 License. /3T-/ t; 1/x,17,, Testing Company Name: A 9;XL)A�r Phone No.:GQ0q 74-1 - in I/z Site Address: ?-9-DO Z'� e e s+.✓7 ST_ Date of Testing/Seryicing: Vale I of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing