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1 � MONRORLNG SE'S "CERTMF#CATION For Use Hy All Jurisdicr bns Within the State of California Auzhoriiy Cited:Chapter.6.?,Health and Safeay Carle,-Chapter--16, Diuision 3, Tisie 23, California Code of Reguixions This form const be used to document testing and servicing of monitoring eguwment.A separate certification or report must be prepared for each mor taring system control panel by the technician who performs the work. A copy of this f Z7; ta system owwr/operator. The owner/operator must submit a copy of this form to the local agency re 3(} days of test date. A. Generai Information ,may 2004 Facility Name: L c* a' / C r� f�i' �u $Idg.No.: Site Address: � ` �f s"1>t fi City: 10-'6 / -a �ENVIRON N Facility contact Person: rl �c Contact Phone No.:( ¢ l ( f Make/Model of Mo " System A hv r 1 Date of Testing/Servicing: /0d/4� B. Inventory of Equipment TesteWCerfilied to fialeate Or Tank m: t . " 1- Truk IM 0 Ip=Taak Ganging Probe. Mudei:k _rt -y +k--11 FqL ' ❑In Tank Gauging Probe. Model: Ammuiar Space or Vault Sensor. Model: )ca- ❑ Annular Space or Vault Sensor. Model- Z "Piping Sip/Tach Sensor(s). 1: 2 Q- ❑ Piping Sunup/'Trench Sensor(s). Model: Q Fill Sump SOMME(s). Model: ❑ MR Sump a)_ Model: ❑ Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. model- 0 Tank Overfill/High-Level.Sensor. Model: ❑ Tank Overfill/High-Level Sensor Model: U Other(MEra 2riEMM=and model in Section E oa P e 2). ❑ Other{ t RE and model in Section E on Page 2). Tank IIT: Tank ID• ❑ In-Tank Ganging Probe. Model: ❑ 1n-Tank Gauging Probe. ModcL ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault.Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model• ❑ Fill Sump Sensot(s). MOdet ❑ fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector_ ❑ Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/ el Sensor. Model: 13 Tank Overfill/Ifigh-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on 2). D Other( i =nt and model in Section E on Page 2). IDt Dir W: (3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Cl.Shear Valve(s). ❑ Shear Valves). Cl D' Containment Float(s and Chain(s). ❑ Containment Fioat(s)and Chain{s)_ Dispeuserw: IIT: Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containnent Sensor(s). Model: U Shear Valve(s). D Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ®Dispenser Containment Float(s)and Chain(s). Dispenow.iia: Dispensw iiia ® Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D Shear Vdve(s). DDis nser CbmaimacuE Floet(s)and Chain(s). ❑ R!!R=Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,cgpy this form Include information for every tank and dispenser at the facility. C. Certification-i the deftwent was._ to seeordwee with the relh , guidelines. Attached W this Certification is " (e g. ` ) necEssary to verify that this information s correct and a Plot showing the layout of monitoring equipment. For any equipment capable of such reports,I have atso attached a copy of the •(chick all that app ®System set-up Technician Name(print): njjj� Signature: Certification No.: License.No' .: Testing Company Nate: C_ [C h4, 'T,tt,) Phone No.:{ �+f?0 �G'6 6 1 Site Address: PO f�Ck 0 OS� 57(') -1 Cad- • 5737r�i 3 -3 i� Date of Testing/Servicing: ' !' Page 1 of 3 03101 Molaftoring,Sy Cerfiffintem a y t e.