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Nov 25 02 02: 40p Fr-nzen Hill 559Q881467 p. 4 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 for 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: 1345)4-e-= r W, Bldg.No.: Site Address: nk<t N S City: yl/)tt}i.t 7-��c. zip: ?536(0 Facility Contact Person: (-1 S S P r•fl P It'v Contact Phone No.:( 2O9 ) 2 3 T 7 r7?8- � Make/Model of Monitoring System:_ V-e-V—'-d-e-it Poor TL 5 -3 S to Date of Testing/Servicing: 7/ S- /&Z- B. ZB. Inventory of Equipment Tested/Certified Check(he seprogriate boxes to indicates ecific equipment inspected/serviced. Tank 1D: t r" # / Tank ID:_ t�S•El-i 3 In-Tank Gauging Probe. Model:_ /Y)49 ( Z In-Tank Gauging Probe. Model: /W*4 q -/ Annular Space or Vault Sensor. Model: F—lo&T Trt 5 -rp— 21 Annular Space or Vault Sensor. Model: >FIDaT- TrtSfn7Sr Piping Sump l Trench Sensor(s). Model: 7c/na,7-Til Stx f c 1T-Piping Sump/Trench Sensor(s). Model:�(o�7--Tri Sys�r ❑ Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: F-x 1 U ;W Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 9 Tank Overfill I High-Level Sensor. Model: WAj Agft_ Ft/lt1e4W_ A Tank Overfill/High-Level Sensor. Model: w 40ao 92). ❑ Other(s ecif a ui menti a and model in Section E on Pae 2). ❑ Other(s ecif a ui ment a and model in Section E on Pa Tank ID: .1)N (,e AD,e D #l•Z Tank ID: lff In-Tank Gauging Probe. Model: 07*!5!- ( Cl In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4t-(A:,7-=r < ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: -e4wT- -r-fj, ❑ Piping Sump/Trench Sensor(s). Model: U.Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mode]: fi,Mechanical Line Leak Detector. Model: F6 t U 0 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: Cl Others ecif a ui ment type and model in Section E on Pa a 2). O Other(s ecif a ui ment tZEc and model in Section E on Page 2). Dispenser ID: ( j Z Dispenser ID: O Dispenser Containment Sensor(s). Mode): Cl Dispenser Containment Sensor(s). Model: Jffi Shear Valve(s). ❑ Shear Valve(s), XI Dispenser Containment Floats and Chain (s). O Dis enser Containment Floats and Chain(s). Dispenser ID: 7 �G/ Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). 15 Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). :—I fDispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). Dis enser Containment Floats and Chain (s). ❑ Dispenser Containment Float s and Chain s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank 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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the re ort;(ckeck all that apply): �System set-up � larm history report Technician Name(print): D6 0 t D L• ✓ X le-r7-r a Signature: � Certification No.: S 5 Z e$I&l et License.No.: Testing Company Name: Fra N z.e v Phone No.:(SS`d }6$S—Z !`�?7 Site Address: 1 DI-) N • S • S 1F• TU later q 3 2- Date of Testing/Servicing: 7 I /62-- Pagel ozPageI of 3 03/01 Monitoring System Certification