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From: Franzen -Hill Inc. To: 12094683433 Page: 3/8 Date: 1/19/2012 11:45:08 AM MONO)RING SYSTEM CERT A TION For Use By All Jurisdictions Within the State of Calffornia Aushority Cited_ Chapter 6.7, Health acrd Safety Corte; Chapter 16, Division 3, Tide 23, California Code of.Regulations This form must be used to document testing and servicing of monitoring equipment. A separate celtWication or regrt must bit-, w- M 4 for earth monitoring system cmitrnl 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 submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Ilnflormation Facility Name.' ESr +A,N.t,_� IM r h,; YtAyj;; r Bld$. No.: Site Address: I LORI ftJ, 5 City: Esc^tyea CK. zip. Facility Contact Person: (2 �� Contact Phan No.: (2SL ) G 3+ g y JA_ MakelModei of Motiitorin S stets[: l:i_y Date of Testing/Servicing: 11431(2- 1t31(2-B. B.Inventory of Equipment Tested/Certified Check thea ro riate boxes to 'indicatespecific equipment ins ected/servicer!: Tank ID: �� 'Tank ID: F * TA -Tank Gauging Probe. Model: LW -t 3Z In -Tank Gauging probe. Model: Annular Space or Vault Sensor. Model: la La -% Ar [] Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: �4. 01 piping Srunp / Trench Sensor(s). Model: [] Fill Sump Senior(,-), Model: 0 Fill Sump Sensor(s). Model. 11 Mechanical Linc Leak Detector. Model: V tAA f Mechanical Line Leak Detector. Modek � QG_C tt7�j ❑ Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Tank Overfill /High -Levet Sensor. Model: yat� �rydurs' in Tank Overfill / Iligh-Level Sensor. Model. ❑.Other (specify equipment type and model in Section E on page 2). [] Other (specify equipment typo and model in Section E on page 2), Tank ID: Tank ID: Q In -Tank Gauging probe. Model: Q In -Tank Gauging probe. Model: ❑ A nnular Space or'(rault Sensor. Model: �,. d Annular Space or Vault Sensor. Model: © Piping Sump / Trench Sensor(s). Model: Q Piping Sump / Trench Scnsor(s). Model; Q Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Q Mechanical Line Leak. Detector. Model: ®Mechanical Line Leak Detector. Model: Q Electronic Lino Leak Detector. Model: ® Electronic Line Leak Detector. Model: Q Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Levet Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on page 2). Dispenser ID: -* `i"Z_ Dispenser ID: --%* 3r!j �gl)ispenscr Containment Sensax(s). Model: %_A .� �jy.� O@Dispenser Containment Sensor(s). Model: 4� ©Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispemer Containment Floats) and Cbain(s). Dispenser ID: S Dispenser ID: 7� $ ®'Dispenser Containment Sengor(s). /Model: �&k_3 3!}q- Dispenser Corttainrnent 3ensor(s}. Model: %_4LS Q Shear Valve(s). p Shear Valvc(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 Contaicunent Sensor{s). Model: Q Shear Valve(s). Q Shear Valve(s). © Dispenser Containment Float(s) and Chain(s). 0 dispenser Containment Floats) and Chain(s), *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. CertitiCatBiton - I certify that the equipment identified In this document was inspecte4lsetvieed in accordance with the manufacturers° guidelines. Attached to this Certification is information (e.g. manufacturers! checklists) necessary to verify that this ittfnrn/Rtlnit i3 Correct and R Plot i'lRtt showing the Payout Of monitoring eliuipsltcttt,. For any egttipm capable of generating such reports, I have also attached a copy off -the report; (check all that apply): 0 Sy ems et= Alarm history report Teellniciati Natne (pxitit): J4ESSi�4_3 - Sigtiatttre: Certification No.: <✓ Z.5" ,SC'7 License. 'Testing Company Name: v -'_ �• �1 Phone No.: Testing Company Address: �kyo e :S Date of Testing/ Servicing: i l 2 Page 1 of 4 UPI -036-1/4 www.unidocs.org Rev. 01AW08 This fax was sent with GFI FAXmaker fax server. For more information, visit: http://www.gfi.com