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For Use ByAh' Juristliclions 1171hin the ,Sinha of Culif- is Awhor-ity C'ileck Cruller 6.7, T/e and Stf/ery Code; C'hnpler 16, Division 3, Tit e Califorrricr Code c f Rcgzrlcrlions This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control 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 agencx,agulatmg UST systems within 30 clays of test (late. A. General information Facility Name: _ S -NAG Ao-ip lv A l 1 (-A W AX Bldg. No.: Site Address: 3`11Y F City: S' i zip: S1-7 / "L Facility Contact Person: C kill I Contact Phone No.: ( 9 i1"� - tfp ?0 Make/Model of Monitoring System: VZ f? ?1:-f ..3! Date of Testing/Servicing: 6 / ) a/ / ox - B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enninmrnt lncnort, Tank 1D: � �— In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model• Vf Piping Sump / Trench Sensor(s). Model• ZJ Fill Sump Sensor(s). Model: I� Mechanical Line Leak Detector. Model: �`i 4 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ecify equi ment type and model in Section E on Pa a 2). Tank ID: (� PIn-Tank Gauging Probe. Model: _ /J' 4 / ❑ Annular Space or Vault Sensor. Model: frI 21 Piping Sump / Trench Sensor(s). Model: ZJ 0 Fill Sump Sensor(s). Model: Zvj fier Mechanical Line Leak Detector. Model• 77- Zb y ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Di penser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser Containment Sensor(s). Model: Zp�- Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). penser ID: {a Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). *It the facility contains more tanks or dispensers, copy this form. Include Tank ID: j/ p Model: yrin-Tank Gauging Probe. Model: /yyr}G Ef Annular Space or Vault Sensor. Model: y za J2f Piping Sump / Trench Sensor(s). Model: Zap fd Fill Sump Sensor(s). Model: jtY Mechanical Line Leak Detector. Model: isles ?JU ❑ Electronic Line Leak Detector. Model: ❑ Tank- Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Paae 21. Tank ID: ❑ In -Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Dis enser Containment Float and Ch n(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). odel: ❑ Shear Valve(s). ❑Dis enser Containment Float(s) n hain(s). Dispenser ID: ❑ Dispenser Containment Sens r(s). del: ❑ Shear Valve(s). at s) a rain(s). formation for every tai k and dispenser a •e lcility . C. Cer$]flCa$iOri - I certify that the equipment identified in t '��oc{ cement was ns ect d/srv� accordance with the manufacturers' guidelines. Attached to this Certification is information .b• , • • ' ( Ists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all theft apph): $System set -rep a—Alarm history report Technician Name (print): ` ,A I/j, �7 ��1,`r� k/P �- Signature: Certification No.: 3'j g %�e C qz 52 3�'? 3- 417' — License. No.: --A 7r/-- A6Z Q Testing Company Name: Z4 �C2 r t A 12-5,r Phone No.:�_ 02)_ Site Address: y��j 1, /�� (�/ Date of Testing/Servicing: 6 Monitoring*,S. Pa„re 1 of �ti 1!3/11 t � System CeI•til'ication �. :l�'e:,a>;lts oi'rE'�°;$cf>!1�/� ef•vi�°��>'e,