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Sep 13 12 09; 18a Elit IV Contactors 120946 342 _ p, 3 •, `..�. ®ts tv Avte:trt °I.JL+It\Jt .�111V1r 'Ise By.t ll Jurisdictions rzzkiir the Stale of C, a. ilutlroriry Cited Chapter 6�r/ rl:and Safety Cade;Chapter 16,l}ivision 3, a`r c%s,California c a ons This form must be used to document testing and servicing of monitoring equipment_A sly tate c_extification araenort must lre�rrenared for each monicoriatt Mstem control Hanel by the technician.who.ptMfotms-the work_ A-ro .r of this foam must be provided-to the tank system owner/operator. The owner/operator must submit a copy of this form to the lo:< agency regulating UST systenns within 30 days of test date. A. "general Info . atio FaciTiijre' ame:....... : .:� ......_.._. .. . _ __......._. :_._ $1dg.No-: . Site Address: — Ci eK: ;Facility Casttact Person � lAContact:Ph .tae No.: Make/Made1 of Monitoring System _ c of Testing(Serviciag_ �. iRt��u LO t71r rC 'u'l t cisco`c a 2;e2ui a^2i iamb Cheek the appropriate boxes to indicate ecific e i meet in edeftervicelk ''1'2aJt IF): 7 'I•agY. 13Yat-Tan&tiauging Probe. Model: [Ij";" ink Gauging Pea! Model: . Y.,... 0 Annular Space"Vault Sensor Moder:� U-A&ular Space or Vac; Sensor. Model: ^ D Piping Sump/-TrenchSensos(s). Model b PipingSump ITren(I :msor(s). Model: a amr{r ens s,. �v(oc7T"-; iUmp _ _ ®McchamcaY Liza Leak Detector. Model: 13 Mechanical Line Leak )etector:• Model: , 0 Electronic Linc Leas;Dezwoe Model: O Electronic Line Lcal1 I :lector. Model: 0 Tankbver(ill/High-Level Sensw'. Model: EI TankOvez511/Fiigta-L c>eYSensor: Madel: Q Other( a i t and tzx�deJ iu Section E ori P 2}_ ®Other tri :rb :a r and rtaodel in Section E on Pattie 2). Tang:FD: Tani:FD m• O In Tank Ganging Probe. Model: L In-Tank Ghuging Pre Fx model- 0 Annular Space or Vault Sensor_ Modck O Annular Space or Vaal `tensor. Model:" O Piping•SumpITrench Sensor(s}.• Model: O Piping Sump IT z: :nsor(s)_• MO&L-- q-Fill Sump SensoF(s)> Molt b:' -. 11 Fill Sanrip.Setisor(s): Madd zz 0 Mechanical Line Leak Detector_ Madel: O Mechanical Fine tsar. elector. Motes 0 Elemoiiec Lute Leak IXtectac :Ivfodei- ® Eicctrestic Line Leak b trot_ Made ®Tank Ovanfe}1l.Iligh-Level Sensor_ Model: 1] Tante CherfriY!Yiigh-Lt :Y Sensor_ Moder: ®Other{ ui f and model in Section it on Pa.e O Otho "f i nx t. and zrtodtJ in Section£on Paye?_ .— Dispenser s ID: Dispeas.er1D: _ ®t�ispenserContainment$rnsor(s). Modct El Di Containrne:nt �-risor(s)- Model: ®Shear valve(s)- O•Shear Valvc(sj 0 DtEE=Containment Floats)and Chain(s). ®Dispenser Containment l oat(s)and Chain(s). Dispenser FD: Dispeaser 1D.- 0 Dispenser Containment Sensoz(s).: Model: [l Dispertscr Containme::t taYsor(s)_. Model: 0 Shear Vaive(s). O"SYiear Valve(s): 0 Dispense(Cbmaintrient as)and Chaff s: O-Di ser Cantaintner t: E.>at s and Dispelrser FD: Dispenser FD: m f 0 Dispenser Containinent Sensor(s). Model O Dislxn!es Containment: :nsor(s}. Model: _ : e ODi Containrneat Floats and Chain(s). ®•D!mLnsrr Conrainmen:J .c+at(s and Chains). , "If the facility contains more tafiks or dispensers,copy this fot#at InclWe'aifoa ration for eryn ,nti iispwserat the facrliry. C. ,L`C)<t Cit iUi>t.-X certify that the egaipnwnt ideutifzed in this d(Imulentu as.irxspeeiedlser ri• +I is accordance with the rnanulac#erers: , guideliam Attacbed to this Certification is infor=tiou(e-g, tuadufacturers> ebecklists):ic tssary to verify thst this information is correct a Plat Platt shavviug the JsyM ofwanits:iteg;niprt Foa'a••}equipment setae L, of generating such rrpatts=F have also attached a copy ofthe report;(cheek/alt�that ap,pl}:. ®System set-tap, •®Alarm h't� :r Technician Name(prim): X g.21Sigaature j� Lj✓,' Cezti6cation No_: � r 7OU License No Site Address: Data:+ f Testing/Servicing: 9 Page I of 3 o310i Monitoring Fi System Certicatioa t ..-...._.:.............. ....... ... ._ . .-_. - . .. ... . ..._... .....g.. .. t. t