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122:,5 5';7588 Maw,Fax GFTTLFR RYAN INC 03:10 31 p.m 10-17-200-6 2 14
<br /> ,10
<br /> MONITORING SYSf6�fficffi, 3171CATION
<br /> 7oar By A IIJurisdictions Within the State of California
<br /> .Out horityCired: Chapter 6.7, Feolth and&2fery Code;Chapter 16,Division 3, Thdo 23,California Code ofReguiations
<br /> This form must be used to document testing and servicing of monitoring equipment, A separate certification or revot-t must be
<br /> iia eoared for each onitq,in by the technician who performs the work- A copy of this form must be provided to
<br /> thz tank system owncr/cperatcr. The ovvraerloperator must submit a copy of this form, to tis-,local agency regulating TjST systems
<br /> willhin 30 days;olftest date.
<br /> Facility Name: Bida.No.:J
<br /> Site Address; '3 �Yz_Y 'Fr-tt, 6 lua city: CA zip- _.3�l Islas 4
<br /> Coi,,tact person: r
<br /> Contact Phone No.: 16 0 C
<br /> f MoTit= st 1/c e 4- Date ofTesting/Servicirg; An, / 2 /0-4
<br /> -, 37, S
<br /> &
<br /> of Equipment Tested/Cerfified
<br /> ae appropriate boxes 10 indicste specific equipmevit jasp d i d:
<br /> T3 S LA V_k 'Tank :_
<br /> -ak -
<br /> au ��m, 0 In-Tank Gauging Probe. Model:
<br /> Gg
<br /> Arinulw Space or Vault Serkson Model: Q Annular Space or Vault Sensor. Model:
<br /> 4 Hlqriek —
<br /> S-_anp, U Piping Sump�'Trench SensoT(s).
<br /> MP Se Model:
<br /> Model: E3 Fill Sump Sersor(s),
<br /> 'a
<br /> 'Mechanical Li-e DetectoT. Model; 0 Mechanical Lime Leak OL Model:
<br /> 0 ElectrguicLine , Detector. Model�
<br /> U Tznk0v:: I�High-Levecc)Sensor, Model:
<br /> Q W-1(spmifV equipment type and model in Sect;A,:,rfi E mi Page 2).
<br /> Tyra rR?; ank XD-
<br /> 0 in-Tank Gauging Probe. Modei-
<br /> 0 Annular Space e or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model:
<br /> 0 Piping Sump/Trench Sensor(s). Q Piping Sump/Trench Sensor(s). Mo
<br /> (s) odcl:
<br /> Z� Fill Sump Sensor(s), R Q Fill Sump Senso
<br /> 34��Iclas,ical)T_i11e7`_.eak Dz�,e4k< MOdci: Q Mechanical Line L vector. Model:
<br /> Lk7?��,ector, Modcl: 0 Electronic eats:Dctccton Model:
<br /> -gh-L-el Sensor. Model Cl T eTfill I High-Level SCIISOT. Model
<br /> equipment type and rno`el in Se-,Von,E on Page 2). Cather(specify equipment typle and anode!in Section E on Page 2).
<br /> ,a9f,e—wer ID:
<br /> • Dispenser Containment Sensor(s). Model:
<br /> • Shear valve(s).
<br /> • Dispenser Cow tairim.ent Float(s)and Chain(s).
<br /> KT} user ID: Dispenser ID:
<br /> 1; 1 0i3' er Containment Sensor(s). 1_wdel
<br /> Cortainrncnt Sensor's). bdel:
<br /> 0 sheax'valve(s). 13 Shear Valve(s),
<br /> 0 Dispenser Containment at(s)and Chain(s). El Dispenser Containmepolfr2oat(s)and Chain(s).
<br /> is enser D: Dispenser ID-
<br /> D, pe aser ipmer
<br /> a t Sensor(s), Model: 0 Dispense ontainment Sensor(s). Model:
<br /> 0 Sh al-vc(s).
<br /> float�s)and ispensnser Cor tai Float(s)mad Chain(s).
<br /> s snore tanks o�-d 'informatior,for even,tank and dispenser at the faciNtej,
<br /> lfth��adiitv Contain jspc��jsers',copy Include
<br /> C., Cerfifleation - I certify that the equipment identified in this document was inspected/serviced in accordance with the
<br /> r
<br /> manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers'checklists)necessary to verify that this
<br /> information is correct a?nd a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such
<br /> rcports,I leave also attached Q copy of the report,, check all that apply): Qsyste set-up XAlarmbi owreport 7
<br /> 11 fee'f; e Signature:
<br /> P
<br /> Certification No.: A-30/ -3 Y License,No.: 2o -;L
<br /> Cc,
<br /> Testing cornpazy Naume: PhoneNo.:(_!2?,r )
<br /> Sit,-Address- Date of Testing/Servicing; 3
<br /> Page I of 3
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