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Jul 31 03 11 : 03a Fr-nzen Hill 5596881467 P. 11 MONITORING SYSTE:N1 CERTIFICATION For L'se 31',411 Jtrr•isrlicrious IfYthin [he State of Cnlrfornin tu,hority Cited: Chapter 6.7, Ne„!!h mid Sriety Care; Chcp!er ,`6• Division 3. Tit!_'3, Cn•'iforn:�t Core of Regulations Tris form trust be toed tJ CaOCl!: eat testis and Sc:�•icing o ntcnt;ori,e e-;:inr:est. •A ;roarste cenit:catien or report must be Prepared for each monitori ;ts?'f 7 co-it-ol pare' b_: the techo;ciar, :.'ho per.`omts~t'.:e U- Jr:. copy of avis for^•t must be provided to the tank syste::: o«rer.'opera:or. Tae 0t177e';Ci)C:aiJC I:: it S i7f?.Il 3 col.•: o:th:s fot-a t0 t C lCc3i age^C r Ula^, t� ca.:sof test date. Y , UST systems within 30 A. General Information �/ Facility'ame: ��7Pr/d�t �2�t ]31dS. No.:�t 3iteAc3dress � Sic. ci^ � ��r<< zip: 9 s ?/__7=acuity Contact Person: S Co—17- f�s Contact Phone No.: r77le�ao • Make/14odeJ of`Monitoring System: (!E'Pced Frc7 ?-G S - ?ems Date of Testing.'Servieing: --/22 /03 3. Inventory of Equipment Tested/Certified :heck thea ro ri.tc to indicates erns"c ui mcnt ins card/serviced: anklD: feGittvr� &n-Tank Gauging Probe. (Model: Tank ID: /P ` 3 c" l� •annular Space or Vault Sensor. 0-In-Tank Gauging Probe. ;Model: �-`(73rrd-�� 4fodel: Q 3y� ^� '2z'4 Annular Space or Vault Sensor. tifodel: Piping Sump/Trench Sensor(s). Model: `� 3' C -2C'� W-.Piping Sump/Trench Sensor(s). Model:��J�� �1 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). 7 ^ �- Mechanical Line Leak Detector. Model: - l U Model: 1 Electronic Line Leak Detector. — C-Mechanical Line Leak Detector. Model: / Model. C1 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model:�W I Other(s ecif a ui menti a and model in Section E on Pa a Z). ❑ Other(s ecif nk Overfill/e ui High-Level est tSenand model in Section Eon P e 2 . ank ID: Ulv(�2 ,P ) n-Tank Gauging Probe. Madel: Tank ID: 7 `l�' ❑ In-Tank Gauging Probe. AnnularSpace or Vault Sensor. Model: 7 Model: _ e �+- Zd ❑ Annular Space or Vault Sensor. Modes: Piping Sump/Trench Sensor(s). Model: '7 � zi�-?E+� O Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump p/Trench Mechanical Line Leak Detector. lvfodel: - ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector, X t Mfodel: ❑ Electronic Line Leak Detector. Nfodcl: ask Overfill/High-Level Sensor. Moder wo,�— ther(s ecif a ui ment t e and model in Section EE on Pa 2). ❑ Oiher fs ecif C1 Tank Overfill leHui enter!Se and modelinSection E on Page 2). Spenser ID: t' 7 _ Dispenser Containment Sensor(s). Model.- —' Dispenser ID: ❑ Dis .-Shear Valvc(s). penser Containment Sensor(s). Model: Dis cnscr Containmcnt Float(s)and Chain(s). ❑ Shear Valvc(s). ❑ Dispenser Containment Float(s)and Chain(s). Spenser ID: 2544 Dispenser Containment Sensors}. lvfodel: ~- Dispenser ID: Shear Valve(s). ❑ Dispenser Containmcnt Sensor(s). Model: Dis en ser Containment Floats)and Chain(s). ❑ Shear Valvc(s). :penser ID: ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Containmcnt Sensor(s). ,Model: Dispenser ID: Shear Valvc(s). ❑ Dispenser Containment Sensor(s). Model: )is cnser Containment Floats)and Chain(s). ❑ Shear Valvc(s). [he facility contains more ranks or dis crtsers,co ❑ Dis enser Containment Float(s)and Chain(s). p py 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. Altached 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, f have also attached a copy of the report;(clieck all that applj): 13 system set-up Z- farm history report :hnician Name (print):Q fit)Lb 1, /NjAd-•7r ,J _ Signature: tificationNo.: zS-7 (Z License. No.: ting Company Name: Ff A";Z�„� �� ( )�$g�2977 Phone tio.:� S. Address: ),I or '0 J S fi % ! �� I c� e' l Z? _ Date of Testing/Servicing: Z2/o_.4 Page 1 of 3 atoring S}'stem Certification 03101