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It ,, <br /> M®NIT G SYSTEM CER CA N <br /> For UAWy AUJurxakdons Within the State ofCalifornia <br /> Awhoraty cued-au pter6.7,Health and Safety Code;dwpmrl6,Division 3.Tek 23.California Code ofRegujww s <br /> This form must be used to doarmctht testing and servicing of motutoewg equipment.A semraate certification or mMrt must be nrepamd <br /> ger each monitoring-system eontrol_pancl by the technician who performs the work A copy of this form must be provided to the tank <br /> system ownedoperator. The ownedoperator must submit a copy of this form to the Ioed agency regulating UST systems within 30 <br /> days of test date. <br /> A. General Information <br /> Facility Name: v i 4>1rJ /• , - Bldg.No.: - - <br /> Site Addarss: ° .,� ✓ �. tti - - <br /> - •._ - %''✓ ✓r' / city. .: .� .- etc- Tip: <br /> Facility contact Person: Contact Phone No- <br /> MakdModd of Monitoring System: i�G S' 5S Date of T=dog/Seavicing. <br /> J <br /> B. Inventory of Equipment Tested/Certified <br /> Ctheatwe a tuners w tnc�icate . <br /> TankID: TW&ED. <br /> tPil1-TankGaggingProhe. Model: TankGW&9Probe. Mudd: , <br /> _ <br /> AanularSpaoterVaultSmm. Model: ✓ Spaoeorwaltscasac Model <br /> !' PipingSmmp/TrcnchSanso(s). Model:_ ,/Land" Stamp/Tamchsensoe(s). Mudd <br /> ❑Fill SumpSaasot(sj. Model• ®TaisumpSeusot(sj. ) Model: <br /> tlf ycchankdLimLakDetectoc Motk,L_„(,.4ZZ2eu,,1 AtMechanicailixLakDetector. Model:- <br /> 0 <br /> odel:❑0octWmcLAWLakDd*cM Model: ®Eloc tw=L neLakDe*%= Model: <br /> �ffTaakONaU/I Seasm Model: dfTxA0vecfill/high9xVdScrim: Model:_h��f <br /> ❑Other( and model in Section Eat EM 2). ®Other( and mold in Section E oa Page 2 <br /> Tank ID: Tank ID: <br /> In Tank Gauging Pwbc, Model: ❑In-Tad:G=Sft Pwbc. Model: <br /> AnnulwSpaccorVaultSensor. Model: ❑ArnnularSpaccorVaultSensor. Model:- <br /> Piping <br /> odel:Pipiaag Setup/Tcaadh Sauor(s). Medd: e^d 9 ❑Piping Sump/Trench Seasor(s). Model: <br /> Q FII Sump Sensor(s). Model: ❑ Fill Suter Sensor(s). Model- <br /> ,�Mechanical Lane Lak Detector. Model -4,�2 62,dclo ❑Mechanical Line Luk Detector. ModeL- <br /> ❑Ionic Lane Lcak Detector. Model: ❑ Ernie Line Leak Detector Model- <br /> erTankOvafall/High4xviclSensor. Modck c> ❑Tanis OvaM/IiighLaielSensor. Model: <br /> ❑Other(s ui in Section E on P e2). ® ( t in Section E on Page 2). <br /> D" spenser ID: <br /> Dispenser Containnaeant Sa►sa(s). Mudd .D"tspauerContainneae(Salsor(s). Model:--- <br /> hear <br /> Valve(s). AT Shear Valve(s)_ <br /> ® D' Containment Float(s) Chains. ❑ D' Containment Pioat(s and Chain(s). <br /> Dispenses ID: 'Dispenser ID: <br /> d.Dispunsa Containment s). Model: 6 ❑Dispe nsa Containment Sensor(s). Model: <br /> hear Valve(s). - ❑Shear Valve(s). <br /> FOShearValve(s). <br /> Containmcat Float(s)and Chains. ❑ Coatainmeat Fioat(s and Chains. <br /> enser ID. Dispensa.ID: <br /> ispensaContaiamentSaasor(s). Model: ❑DispenserComtainmentSensot(s). Model: <br /> ❑Shear Valve(s). <br /> E32MZM Containment E29 and Chains). ® RE=Co tiinaaent s and Charms). <br /> *If the facilitycontains tame tanks ordispensers,copy this fern Include information forevay tank and dispenserat the facility. <br /> G Certification-I certify that the equipment Identified in this document was inspectedhe yked in accordance with the manu(acturers' <br /> guidelines. Attached to this Certification is information(e g.mamdacturecs'cheddists)necessary to verify that this information is <br /> correct and a Plot Plan showing the htyotd of monitoring equipmeat. Roc nay capable of gemm reports,I have also <br /> attached a copy of the all that apply)-^/�i 1*stem set-up - <br /> Technician Name(print): v'�Gd/e-./° Signature: <br /> Certification No.:_ "46zi,-2 License.No.: d.Z <br /> Testing Company Name-T���`�` ,+� —y r c-a c�mQ Phone No--(BA. ,$`n-7®A 0 <br /> SiteAddrrss:Z tiZ �ur �k ®u ' Cii:it'h1L to 9150IC Date of Testing/Servicing. <br /> • r:���t..f3 rr}mai <br /> !I<uhitariu_�.area C.•rrtitirhti<u�,�,„,, <br /> • . �5 '-ti»�''�i`,Gt°�`�. ,,,,fir 'tayt- '�'��a- „�' - <br />