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May 14 04 01:36p 209.956.0214 p.10 er ,T=72.. ■ MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited Chapter 6.7. Health anti Sgfetr Code. Chapter 16. Division 3. Title 23, California Code of Regulations 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 agency regulating UST systems within 30 days of test date. A. Uenera Facility Narm [g. No.: _._F...�» Site Address: `% City: = _ Zip: FacilityContact Person: Contact Phone No_ Z .1 %..� � Y611AC, Make/Model of Monitoring System:10 ✓,- 4.4 `%� j j"-6 Date of Testing/Servicing: /_ZZ/ QY B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecifee enninmrnt i-9 Tan • ID: ( %'4 Tank (D:2 In -Tank Gauging Probe. iYAnnular Space or Vault Sensor. Model: 18 y7 " - 'C) 7 ein-Tank Gauging Probe. Mode[: 7 - AD Jar'Piping Sump /Trench Sensor(s). Model: i/ y2Q Model: f�nnular Space or Vault Sensor. Model: 7 %7 WrFill Sung Sensers). $4 Q"Piping Surttp / Trench Sensor(s). Model: 79 3' �1c: Model:} i o'tS Zu Er,.� ®F ll Sump Sensor(s). Model: 7;�Y-r ❑ Mechanical Line Leak Detector. Model: O Mechanical Line Lcak Detector. Mode[: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor_ Model: 0 Tarek Overfill / High -Level Sensor. Model: O Other (specify equipmentand model in Section E on Pa a 2). ®Obiter a' and in T2SY ID:.I&fE'In-Tank Gauging Probe. GYAnnular Space or Vault Sensor. Model 9 Y;7 %�� ❑ In -Tank g 1: q=2 S / Trench Sensor(s). Model: �Y C, - Model: ❑ ular S or Vault Sensor. Model:ErPiping E7 Fill Sump Scnsor(s). 7y 3 � `7 ❑ Piping S / T s). M ® Mechanical Line Leak Detector. Model: � u ' r Model: ❑ Fill Surm Sensor(s). ❑ Mechanical Line Model: Modek ❑ Electronic Line Leak Detector_ Model: or_ Cl Electronic Detector. Model: ❑ Tank Overfill 1 High -Level Sensor. Model: Q T 11 / High -Level Sensor_ Madek C1 Others i !Eu i and model in Section E on Pa 2)_ er ni Y and model in Section 1; an Pm 2 Dispenser ID: - Dispemser ID: 4 W1:;iispettset'69ttainttt 1 Smsot(s). Model.• ?,7,y� iirv-pensercontainment Sensor(.)_ Mode[:y �� c -Id ^------ Shear Valves) IrY'S lseai• Valves)_ . ❑ Di ser Containment U s and Chain(s). Q Dispenser Conwinrnent Float(0 and Chain(s). Dispenser ID: spenser i;D: 3,'ShSh pertser Containment Sensor(s). Model: 1'✓ l� - �t7lw - ❑ Dispenser Containment Sctrsor(s). Model: [ear Valve(s)_ 0 Shear Valve(s). ❑ Di user Containment Floats and Chains .❑ Dispenser Conminarentt Floc s) and Chsi s). Dispenser ID. Dispenser ID: j Containment Scasor(s). Model: ` ❑ Dispe xiser Containment Sensor(s). Model: ❑ Shear � Valve(s)- i9 `�s) ❑ Shear Valvc(s)- ❑Dispenser Containment Floats) and Chain(s). O nser Containm^nt Ftest s) and C nin(s). °If the facility contains more tanks or dispensers, copy this form Include infotrnation for eve. • tank and d< r : °} ,.c -t .sscr a' the facili;',. C. Certification - I certify that the equipment wa identified in this document n.•,, u - iP ..5 inspect ..�..,�,,sea guidelines. Attached to this Certifrcation is information (;,g. raanufzcture e'ceu.�s� cceSs7! �) g r3 to Verify that reei!) retlOriria rnri ss correct and a Plot Pian showing the layout or monitoriitg ctjttr`i�s a:r a93 egttilrrr t R r r <<; :. attached' copy of the repo -•rt; /check a1I thatc/s yj: 3stesri sCt-uk, $ Q. :tt3�Vij r,c�-'`'; i,,�/ - - - technician tdartie (print): (/ `� t�Ct `" 2. � ..._-� Signature: 6 j Certification No.: �� ( License. No.:�3� 7 esting Company Name: �.�CICS----t�-L{•" - -- Phone No.: Site Address: , Date of Testine/Serviceng: e7l r r-. _.:r:__.c__ F'atie I of 4 ONO