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M N NSYSTEM TFT$ ` 1 P- Ilse 6v.-111 Jarisehctions Within the .State of Califbrnia k `{gg�� Authority C'itecl• C'halver 6.7, Health ancl.Sclfety Code; Chap/er 16, Dmisioaa 3, Title 23, California C'o(IJ"1 �.l2e rt�cc��itifii,p7 This form must be used to document testing and servicing of monitoring equipment. A separate certiofitio;n or rpnat i prepared for each monitoring system control panel by the technician who performs the work. A copy of this fbrrn,must 66 pr6i0j.�l to the tank system owner/operator. The owner/operator must submit a copy of tll , form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: C �Ll Gn�Nlls. CA 12 � Bldg. No.: Site Address: 3423(/ E 414A 'M&O. Lit) . city: HJT®c_14_"g06--a Zip: 1Z Facility Contact Person: AC/a/2('j Contact Phone No.: O %S/ - YC®Ya Make/Model of Monitoring System: V65Z.C4 DoT 7 -L:5 -55C3 Date of Testing/Servicing: 125-10-7- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: g -T- 0C--1 �% ( C�-"T 0 In -Tank Gauging Probe. Model: ] 1 ing Probe. Model: JO Annular Space or Vault Sensor. Model: ® 7AimUlare or Vault Sensor. Model: K Piping Sump / Trench Sensor(s). Model- e / Trench Sensor(s). Model: Z�Jl�I Fill Sump Sensor(s). Madel: ?O�sor(s). Model: wog XL Mechanical Line Leak Detector. Model: Lt> Zoog ®--Mechanical Line Leak Detector. Model: 10—Z4.. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e ui meat ty a and model in Section E on Pa e 2). ❑ Other (specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: es c - L- ❑ In -Tank Gauging Probe. Model: 94 In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ZU ❑ Piping Sump / Trench Sensor(s). Model: A Piping Sump / Trench Sensor(s). Model: �F ❑ Fill Sump Sensor(s). Model: 4 Fill Sump Sensor(s). Model: g ❑ Mechanical Line Leak Detector. Model: ` Pt Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _1Zobc ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: P Other (s eci a ui ment ty a and model in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Page 2). spenser ID: / `� t� Dispenser ID; Dispenser Containment Sensor(s). Model: Ze7C" LQ ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: -,;7 f- r- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Zd% ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 56 (,12 Dispenser ID: ❑ ispenser Containment Sensor(s). Model: Ze7E ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). is enser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chains . *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equr went. For any equipment capable of generating such reports, l have also attached a copy of the report; (check all drat apply): Systetn.,,,T t -u ® rm history report Technician Name (print): Signature: Certification No.: 803 License. No.: `tl` � �3�- Testing Company Name: A n _ S r Phone No.:(°,��>_'r`rt `� L)i� Site Address:. �/2 Date of Testing/Servicing: 6 Pagel of 3 Monitoring System Certification A Results of Testing/Servicing 03/01