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Jul 08 09 11:33a Elite Iv Contractors Inc 2094616342 p.2 <br />MONIAORIXG SYSTEM CERTWATION <br />Fir• CIse Ki::.:. <br />xzcd oni a Cided: Choprer 6.7. ffe*a/rh and Sajcry Code: rhaprer 16. Diesdio►r d. Erle 63. Calgfornia Coda or'Regudartons <br />This form must be used to document Luing and servicing of taxonitormi g equips cni. If more than one <br />momltoring system control panel is installed at the facility,0rarra r cotsficatiop�Se p^rt mf AVcd fur <br />each by the technician who performs the work. A copy of this form must be <br />provided to the tank !Wem owner/operator. The owner/operator must submit a copy of this form to the local <br />agency regulation; UST systems withiD 30 days of test date. Insu'ucti®ns are printed on the back of this page. <br />A. Genera! Information <br />Bldg. No.:__ <br />Sim aQd_*Csa:—f��1=-/-� %C „ -- Czsy' �•G�e� - - zip P <br />FROity Contact Pew: i GCS Contact rho., Alb: <br />MAkx'Uodel afmanxto6ftff sysic= TL 5 ` -v Sedf ,tt of�TesnnglSelrvieiag:.c i <br />B. l:aveanttory of Equipmelas,Tested/Cet•*Wed , <br />Cheek the , ate boxes to Indicate a idleul meet las <br />Tame Ll7 <br />0 to -Task Ptrbc. Model: <br />fit AnAbtat SPACe or vault scmar. %%&L <br />pipmg S a). Madel: 2.? <br />D FiU sump s). Model: <br />if Mechanical Linc Leak Daector. Monet; _:L.0 (,I e� <br />D Electra Aic Line Leek Detector. A$odel: <br />O Tarek Overfill 0 HiO.LCVrj sensaar. %)odcl: <br />0 Ai. Scarpr(t). Model: <br />jEi `,ht:ar Valvc(c), <br />Dia Cmaunnew Floats) and Chniat(s). <br />Cif t and model in SecGoo E tm Pu_qt:!). <br />TV& FD: <br />Q In-Tmk Gouging Moder <br />0 fstmmeetar Spic! or vault $peens. Model: <br />Q Piping S wnch sen.ar(t). Needed: , <br />0 Fill sump srasorK:j. Model; <br />0 MCchnniarl Line Leak perecror- Model: 7L _MQ <br />Ci Electronic U ne tails Oexecuor. Model: <br />R Tw* Overfill f High -Level Sensor. Model: <br />0 ENspetser C".ar r sem w(sy Modal: <br />Q va"G). <br />0 Di:pnaa Containment FIDat(a) and ChaiN(s). <br />Q Ofha (s ( u4 and model in $4c6*n E on Pane 2), <br />weted/setviced: <br />Laude _mom <br />O In -"f auk G.uee� Probe. Mgdc-l; <br />yar Amiulw Sic at vault sensor. Model= Nf ;L.O <br />fl Piping Sumprrrench Sere =6). MWEL <br />O Pill StunpSenwr(s)" Model: <br />Mechanical Line Le -k t?oee=or, Modr:i: I•L47:' <br />0 Electronic Lint Leak Deteeror. Model: <br />Q Tank Ovedtll ! It stt-Level seat W. Model: <br />O Oispouer contwnfnent sensor(s). Me4eL <br />Cl Skew vah+r(e). <br />Q DiVensff Cantainatent Floar(s) and C3atn(s). <br />0 Others a if co!LiEmnt tME and mudsl in section E on rare ? . <br />T&Mk W. <br />0 le -Tank Causing Probe. hlod$: - <br />Q Anetular.Space or vault Sensor- Model: W <br />Q Piping SwppjFCrjCh $rnsoQs), Made): _ - <br />Cl Fill Sump senuff(9). Model: <br />Cl MccbanicW Linc Z ak acre a". Mo&l: - - <br />U Eleceronie Lac Leak Ovector. Model: <br />Q bank Oveal / High -Levet Sensor. Model: <br />O Dtspen:a Comini meeru Se sor(c). Model: <br />® Shea- Vedve(a)_ <br />D Dispcma Containment Float(3) and Chain(s). <br />O Other (s ifs 53urprnent tic and model m Secsi wn F on Pace �}. <br />C. Ce C:ttt►lf - f e ertlfy that [ltc ee}n:ipment identified in tW doettment was inspe cted/serviccd in -accordance erith the <br />t +ns i�pes, Atttielitd to this CerriRcarlom is informtativa (e.g. amenfactureTV ehecldists) necessary to <br />verify that this info on is correct qned a Site Pion showing (be layout of mor hioring equipment. For any equipnsent <br />capable Of =r flag sash repOrts,l have also ■trached a copy of the (check elf rlFar epplrj: O Sj�:tce� Let-icp i•Tporr, <br />® k1story report. <br />Tiodmisian Name ( ' t): v t*/ <br />taftJLie. No.: SiEna[rue-. v e►` �r-�./��li <br />Testing Company Name: <br />