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-�. V cVJ VVJIJJ r Lr to rL_uurc t'Aut CIL k MONITORING SYSTEM CERTIFI ATION For Use By All Jurisdictions Within rite State of California Authority Cited: Chapter 6.7,Health and Safety Code: Chapter 16, Division 3, Title 23, California Code of Regulations This form trust be used to document tcsr(Ag and servicing of monitoring equipment.A Sen atz certification or reportmust he prepared for each monitoring system control vans]by the technician who performs the work. A copy of this form trust be provided to the tank syF-tecn c,wncr/operator. The ownerloperator 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: ( es4- &ere_ ,CVli( Bid&.No.: Site Address: 33 C7 d we st(An'L City: S+0('Xt '-v _ zip:ef' o oL( Facility Contact Person: :5 44,/-Cr n Contact Phone No.:(o?Ol )zt'G 4 (&S-L Make/Model of Monitoring System: I C d&r.12vof-z IrL S '300 C Date of Testing/Scrvicing: t D B. Inventory of Equipment Tested/Certified Check the 22propnate boxes to indicates Kine t uI ment ins etted/xrAced: Tank ID: ie 0 v I&ver' U l--- 51s' " Tankill): Sty pr e-k"e:. U-et t<,A.od Z I n-Tank Gauging Probe. Model: 5l�" 1p Pilin-Tank Gauging Prole. Model:xY-7 3`3 0--/oT ..a Annular Spacc or Vault Sensor. Mode1:d 79N3jo- 4?� O'Annutar Space or Vault Sensor. Model:t�Z`1 d"Y' 20 U Piping Sump t Trench Sensor(s). Model:1j'79439d— ZIP_ Z Piping Sump/Trench Sensor(s). Model,.67993SQ -ICS O Fill Sump Sensor(s). Model:_ O Fill Sump Sensor(s). Model: .,QT Mechanical Line Leak Detector. Model:��A- _L� 0 Mechanical Line Leak Detector. Model: Q'}� ❑ Electronic Line Leak Detector. Model: Q Electronic Lint Leak Detector. Mocicl: O Tank Overfill I High-Level Sensor. Modcl: Q Tank Overfill/Nigh-Level Scnsor. Model: O Other(specify ui ment t and model in Section E on Pa c 2). O Other(si;LeLcify equipment t e and model in Section E on Pact 2). Tank ID: Tank ID: O In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Q Annular Space or Vault Scnsor. Model: D Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Modcl: O Fill Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Lcak Detector, Model: O Electronic Linc Leak Detector. Model: O Tank Overfill I High-Level Sensor. Model: O Tank Overfill I High-Level Scnsor. Model: O Other(s cif ui meat t e and model in Section E on Pagc 2), 2.2 ther(s ecif s ui ment t t and model in Section E on Paye Z). Dispenser ID: Dispenser ID: 3 O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ErShcar Valvc(s). 2'Shear Valve(s). A-Dis nser Containment Float(s)and Chains , .EeVis nser Containment Float(s)and Chain(s). Dispenser ID: — Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Scnsor(s). Model: ,O'Shea Valve(s). *Cr Shear Valve(s). P,,Dispcnser Containment Floats)and Chain(s). •a Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 1] Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve($). O Shear Valve($). DD s iits r e Containment Float(s)s and Chain(s). 13Dispenser Containment):lost s and Chain(s). Coma ) •If the facility contains more tanks or dispensers,copy this form. Include information for everytank 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 equip went capable of geoerating such reports,I have also artacht:d a copy of the report;(check all that apply): O System set-up aAlarm history report Technician Maine(print): /_.o/ A - (,tJ r'(f r'G. Signature: y,- zz;=�_ Certification No.: Sf I U ZyY?1 License.No.: 031(go Phone No.: 20 4-8 Testing Company Name: ,, � ��-33 DtD WGSf-( • S1'U�kh� Date of Testing/Servicing / / o sitC Address: 33 _ �e. rt ---- Page I of 3 03�Ot Monitoring System Certification e:�Pk� L�wovy-"'�L r'" or