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MONITORING SYSTEM CERTIFICTATION F E B 0 '5 2003 For Use By All Jurisdictions Within the State of California Authority Cited.,Chapter 6.7,Realth and Safety Code;Chapter 16,Divisihn 3, Title 23, California Code -A '#q44'Aw H� j PS- E This forth must be used to document testing and servicing of monitoring equipment.A separate certification or reo�"ft, 4p6 for each monitoring system control panel by the technician who performs the wof)L A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this farm to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: kCkl I M CAIAL 1-10S4217;i C Bldg.No.: Site Address: 4 S S. 'tw/Lz M A'r— City: zip: Facility Contact Person: /2Cz!2XL/ 1?0;EHR1C-W- contact Phone No.:( 2,c2-% Make/Model of Monitoring System: AvleAtj X761 Date of Testing/Servicing: _LI_3L_I_o B. Inventory of Equipment Tested/Certffiled Check the=Mriats b..ei to fndlcatesserviced: Tank M. I Tank ID- 0 jnzTauk Gauging Probe. Model: 1n-Tank Gauging Probe. Model: "nular Space or Vault Sensor. Model: 13 Annular Space or Vault Sensor. Model: 2'Piping Sump I Trench Sensor(s). Model: F164Y Ka C1 Piping Sump/Trench Sensor(s). Model- U FLU Sump Sensor(s). Model: ®l=ilt Sump Sensor(s). Model: Q Mechanical Line lzak-Detector. Model: 0 Mechanical Line Leak Detector. Model., 13 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model- ❑ Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. -Model: 13 Other( .Lui2meat and model in Section E on E!Le 2). C1 Other(ffuipment=and model in Section E on PaLe 2).,__ Tanis IDs Tank ID: C1 In-Tank Gauging Probe. Model: 3 In-Tank Gauging Probe. -Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Modeh Q Piping Sump/Trench Sensor(s). Model: U Piping Sump/Trench Sensor(s). Model: 3 Fill Sump Sensorfs), Model: El Fill SU-MP Sensor(s). Model: 13 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. -Model- 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 13 Tank Overfill/High-Level Sensor. Model: C3 Tank Overfill/High-Level Sensor. Model: 0 Other(=jLv Sgui2 ESnt=and model in Section E on Page 2). 0 Other(spcciD;:ff!p Nmens pM and model in Section E on e 2). Dispenser ID: Dispenser ID: 13 Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). M DisL3enser Containment Float(s)and Chain(s), 3 Pin?S3ser Containment Floar(s)and Chain(s). Dispenser ID: Dispenser JD; D Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s), Model: Q Shear Valve(s). 0 Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). C1 Rnspenser Containment Float(s)and Chain(s). P.Dispenser:ID. Dispensa.ID-, Dispenser Containment Sensor(s). Modeh 0 Dispenser Containment Sensor(s). Model: 13 Shear valve(s). C1 Shear Valve(&). C! Containment Float(s)and Chain(s). 13 Dispenser Containment Float(s)and Chaia(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 eer-ftly that the equipment klentirled in"doeummi was W�ffi in se with the manufacturers' guidelines attached to this Certification is information (eg.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 report-L(check all that apply): 0 System set-up U re rt Technician Name(print):_ Signature: 6r, 1 2—ntn Certification No.: License.No.: Testing Company Name: 1-7 1-1(o;,i 7;F* /- ZQJ Phone No.: L/ A 19,f f/-,T e, I -LI-1 "x 1365115: �'144c'Cly Date of Testing/Servicing: Site Address: ;7 Page I or 3 03/01 Monitoring System Certification