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MONNIARING SYSTEM CEW114AXION For&-se ' -H Juris&ctions Within the State of California authority Cited Chapter 6 7, Health ard S*V Code;Chapter 16,Division 3, 'Title 23, California Code of Regulations This formol must be used to document testing and servicing of monitoring equipment.A separate certification or report must be REMared for each,montgr Lg Zgem control panel by the technician who performs the work- A copy of this form must be provided to the tank system ownerloperator. The owner/operator must sub-nit a copy of this form to the local agency regulating UST systems within 30 days-of tw,.date. A. General Information Facility Name: oew- Bldg.No.: Site g- 1 ear City: Zip: Facility Contact Person: K0 b Contact Phone No.:(La:!L2J-04(>7 17? Make/Modell of Monitoring System- Vg4&.1jE !R�-S a " 4> -Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Chak the -ate boxes to indicate USSific SLuipment iugg!jn�rmed: Tank W: pe,-Z-- Tank ID: Tarok In-Tank Ga�ging`Probe. Model:-7 5r'AP-9/7-15,0>7 PE In-Tank Gauging Probe. Model: -7 In-Tac=k Gal Annular Space or Vault Sensor. Model: 1%Annular Space or Vault Sensor. Model: ,n Piping Sump!Trench Serisor(s). Model: APiping Sump I Trench Sensor(s). Model:.-!�4;�,- -71 12 Fill Sum-,Sensor(s). Model. C) Fill Sump sensor(s). Model. Meehan-Ical Line Leak Detector. Model: V R- e Leak Detector. Model: a X Mechanical Liq 0 Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ;S Tank Overfill 11 H;. -Levcl Sr. Model:gpfW- C. 50 -Lvrel Sensor. Model: 91, %Tank Overfill I High C1 Other(specify equ!RM.',pE and model in Section E on Page 2). _0 Other(specify ui ent=and model in Section E or,Page 2'. Tarok ID: P112-6. Tank ID-. J& In-Tank-Ciao rng Probe. Model: b— 0 In-Tank Gauging Probe, Model: �IL Annular Space or'W'aWft Sensor. Model: Is 17 C7 13 Annular Space or Vault Sensor, Model: t$-Piping Sump/Trench Sensor(s). Model' 13 Piping Sump/Trench Sensor(s). Model: U Fill Sump Sensor(s" Model: 13 Fill Sump Sepsor(s). Model: Mechanical Line Leak Detector. Model: Y, 1jL E3 Mechanical Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector- Model: f;gtank Overfill/High-Level Sensor. Model:. 55 0 Tank Overfill/High-Level Sensor. Model: 0 Other(si>ecify equi==and model in Section E on EM 2). 0 Other(a=;[ X MuieMat=and model in Sect-Ion E on Page 2)- Dispenser ID: Dispenser ID: -.3±:!5� ;LDispenser Containment Sensor(s). Model:ZgAx�� TADispenser Containment Sensor(s). Model: !S-� 0-Shear Valve(s). 5bnApvalve(s). D$ ser Containment Flo! s) Chain i;L Dispenser Containment Float(s)and Chain s). Dispenser 9;-441 Dispenser ID: PLDispenser Containment S-e--.i—w,(S). Model: 6�- e X ff�7 � PQ Dispenser Containment Sensor(s). Model. 572�-4F?Qj, %Shear Valve(s). W Shear Valve(s). ZDiuser Containment Float(s)and Chain(s). Containment Float(s)and Chain(s). a Dispenser ID: Dispenser ID: U Dispenser Containment Sensor(s)- Model: 13 Dispettser Containment Sensor(s). Model: L) Shear Valve(s). 0 Shear Valve(s)- ODi ser Containment Fl )and Chain s). 0 RLTM=Containment Floags)and Chain(s)- *Ifthe facilit=y 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 ins iced in accordance with the manufacturers' oVidelines. 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 equipmeaL For any equipment capaMe cif enerating such reports,I have also attached a copy of the report;fcla i ghtu qy): -3 System set-up 0_ history re Tecimician Name(print): vte-_e Si Certification No.: 4?6 Y.;L— License.� Testing Company Name: Phone No.: 57.>— tt!!��:251 Site Address: Ec—> Sc;�x z5Date of TestingiServicing: Page I of 3 03101 Monitoring System Certiftation