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L ! MONITORING SYSTEM CERTIFICATION For Use ay.'tll Juristliciions Within the State of California Authority Cited: Chapter 6.7, Health and Sgfetp Code Cliwjler/6 Dn isir7 3 Title 33, California Corte of'Reg"uhaions This form must be used to document testing and servicink' badti:ng Wp t. A separate certification or report must be prepared for each monitoriii7 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 subojjt actp p2(Wform to the local agency regulating UST systems within 30 days of test date. A. General Information ENVII s, 'a+ NT HEALTH LT Facility Name: r 1 m O✓ PE'i;lest i/'SERVICES Bldg.No.: Site Address: 9-7 5 5. TGI'rt 0h"tL Avc City: �-Odi Zip:=t=19! Zqo4� Facility Contact Person: '2ay)CLO Contact Phone No.:(ZQ9 ) -— -7 51 Make/Model of Monitoring System: Vb 'bilK,- •1 r IL Date of Testing/Servicing: !0 /Q3 /08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: Tank ID: AIn-Tank Gauging Probe. Model: M Or G ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: LS - 3 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: L, - 3 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: ❑ Other(sEcify equipment t e and model in Section E on Page 2). ❑ Other(s eci equipment t e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ 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 Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: LDisgnser ther(s eci equipment t e and model in Section E on Page 2). ❑ Other(s ecif a ui ment t e and model in Section E on Page 2). ID: Dispenser ID: spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model•hear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. InCIUde 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 report;(check all that apply): ❑SvAte up ❑ Alarm history report Teclinician Name(print): Felix Ramirez Signature: Certification No.: License.No• OTTL#08-1740 ICC#52//7,`3934-UT Testing Company Name: Af t l Phone No.:( 09 ) 7'h`t- 0/12- Site /f2 Site Address:-7F5 5 h`niry'Y r14 ave Date of Testing/Servicinq:0 /0,3 /00 Page 1 of 3 03/01 - Monitoring System Certification A Results of Testing/Servicing