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MONITORLNG SYSTEM CERTMATTON, <br />For Use By All Jurisdictions. Within the State of California <br />Authority Cited." Chapter 6.' Health and Safety Code;' ter 16, Division 3, Title 23, California Code of Regulaaions <br />This form must be used to document testing and semcing of monitoring equipment. A semate certification or report most be vrevared <br />for each monitoriag_systern control panel by the technician who performs the work. A copy of this form must be provided to the tank <br />system ownerioperator. The ownerioperator must submit a copy of this form to the local agency regulating UST systems within 30 <br />days of test date. <br />A. General Information <br />Facility Name: > `-t- f'LM— ' r '� P Bldg. No.: <br />Facility Contact Person: <br />Contact Phone No.: ( <br />-._ <br />. .. � _ .k: f of i i i 1 i is 1: tSystem <br />Date1 TestingiServicing. <br />^ 1'I: <br />B. I ,.,. I t + of EquipmentTested/Certified <br />Cheek <br />e� <br />t ♦ t.. ^' .. <br />4 ! 'J. {.. ". Probe_ y;.t... <br />1s. , •.it GaugingModel: <br />Q: 1 . 1 :r5 _x i '. Probe. ! (♦ i�' <br />Annular Space 1 VaultSensor. t 1.. - N <br />r'. `. 11 f. .t.. Space A�:VaultSensor.: :t t+ ; <br />•..,.. t.+ AilTrench :+1 �. t!'. td -' —.I <br />. -I 1 +. I: Ilf Trench 1.Sensor(s).•-1 w.77 r: + <br />� <br />isiifTil cds;.1. Model:- <br />t <br />L. a it4tf. :'iM1ge i.is ♦'1e <br />isMechanical line :✓.. Detector. I t..... <br />iMechanical t .✓.:. Detector. Modch <br />E3 Electronic lia t a Detector. I r.::. <br />i:. EUccumInic Uw Leak Detector- `_ s re �. <br />is Tank:i at. I W* Sensor Model: <br />i Tank Overfill / .i•4. -vel Sensor -<:It., <br />0 Other(sped I`IR1111."r `Y." .ilf if it �' C :+. sit. bf ' <br />� i • I.y I+M1 .r 4tti t �1... nit it il.:' I] ss1 Ia : <br />f <br />n �1> <br />. <br />t ^ 3' t!" ♦/' <br />ila-TankGauging ' ff"iC" <br />l ♦: <br />r Space t: <br />.VaultSensor., {1 . <br />13 .t.1=- 1 <br />`A1 <br />.{%4.VaultSensor. <br />g. ipin . Sump I Trench «91. ♦ . '. Model: el: 1 Piping Lm r Trench i. o f ': odc <br />EMechanicalA--- s.':. Detector -- 1 i.A;' : <br />i Mechanical n; Detector- :.. ,>, ts.- <br />! Electronic Li1e Leak Dut:.rttr. Modch <br />i'. Oectroific Line>.:.:. Detector. tett. '.'. r i r L <br />U Tank Overfill Wa ut Sensor. ♦:ri'. <br />■' Tank • .a t`f: 1 '�[of Sensor Model: <br />.:_. •' 1! .+:........ 1, _M S "r 1-Y.1iY�1 i{ �1_... �'v ..:i f Ci 11._ _. {_ msµ_. f t r=. <br />* Section E on Page 2). I' <br />.... __... _._ i ` 1. .! J I,�y_.l ll1 tlI ._-and-model li <br />Its�.r i,:fi f+F 1'itl ilir wi.: -, •♦.: 'i i;' <br />3,n1. -.:. t^l .a tJt,-:'1 *.-.5-175 <br />: v i µl :+ y..F :. :i IiA/•" S ♦u .. ..iclA.:rf <br />�: �. i ..', i 1 itiFt i 577Q177 LIN1..1Ii. . <br />41: <br />171 Y If .. <br />i i „i..'t,": trwsv nli a{:: ..i. i.. t r,' <br />i x,.1..1. �.� tr vra. fl�:rf ai.'♦. :"tt- <br />.: �i <br />�t <br />� i ..1�" (... x .+ t n.,;~i. r . .at t i . r: , <br />/ ► f r a r .rA1luff+ +".: AA�f #Fr..xart; �'. <br />111 ► 5aF m Li....k itll.Pt til t -ie <br />i. #"' <br />.,1 <br />VWTO <br />c mitC fI �V#itfl �} :f.A I.tZ,�:1 <br />C >;.f iw:r I�i...;1i131tryS.?1.1:LI t I <br />the beilitycontains mom I*: &spensers, copy this4rti Include t irmad t'. bDr every^)i and 1ispet'e.. at thefacility. <br />C. Certification .....„s ..,.,':::il . .i:f: ... ...,. :..;: <br />„ .ts: 'J. .s i:' -*Ah (i' <br />' 1 _ efi +s, Attached cte t fbis'CerWication s j. { ssfi.I.i (eg. mususiacturew 3 et w it.; necessary 1.veripyA•,;., this '.io i n <br />ii and Plan showingtlayout t: �!' S-t«i yi� i capableAgenerating I , <br />attached a - iVthatapply):E <br />W- set-up <br />Technician <br />Certification No-- <br />t <br />License. No.: To q <br />Site Address: Abs JODX L3`C27 SAC-RAAWA40 <br />44. 1"C'S11 Date of TestinWServicing. ILZ--� 17 /.9-3 <br />Pap 1of3 <br />l i t I.: I f' t t i -i <br />