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r 0 MONITORING SYSTEM CERTIFICAT.104 JUL 1 7 2008 Foy Use G'i 111,/rri isdirliun.r 11'ilhin the.Slide (?f'('alifi)rnia A1111rori/n C'ite(I C'hapler 6.7, flectllh and Safc�li�Curie; Chci/ale r l6, Division 3, Tille 23 C(11l forniprf�Yt This forni must be used to document testing and servicing of monitoring equipment. A separate certific 11_116 or Choat must be prepared for each monitorinsystem 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 clate. A. General Information Facility Name: ®LG-5 Bldg.No.: Site Address: 3 /GVic Tpe City: 40,bl Zip:�Z Facility Contact Person: /,3/ �/�v Contact Phone No.: ( Make/Model of Monitoring System: Ir 5 -Z 50 9 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check tile ayeropriate boxes to indicates critic ee ui ncent ins ected/serviced: f90 ank ID: �-'� Tank ID: 42c,-T- )0 c,-r- In-Tank Gauging Probe. Model: In-Tank:Gauging Probe. Model: Nl Annular Space or Vault Sensor. Model: 6 f�--Annular Space or Vault Sensor. Model: �F Piping Sump/Trench Sensor(s). Model: 2®' lL Piping Sump/Trench Sensor(s). Model: 5 Fill Sump Sensor(s). Model:_ _ ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leal:Detector. Model: &Mechanical Line Leak Detector. Model: ICX---%�— ❑ Electronic Line Leal:Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment type and model in Section E on Page 2). ❑ Other(specify e uipment t ie and model in Section E on Page 2). Tank ID: el =-c--T Tank ID: 04 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model• ;4 Annular Space or Vault Sensor. Madel: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 2U�, ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:_ ❑ Fill Sump Sensor(s). Model• .a Mechanical Line Leak Detector. Model: ,IC-® ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Page 2). ❑ Other(s ecify equipment orient ty e and model in Section E on Pa a 2). Dispenser ID: I"f-Z Dispenser ID,- -� l� Dispenser Containment Sensor(s). Model: t10( A Dispenser Containment Sensor(s). Model: p J4 Shear Valve(s). A Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: fif Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: If Shear Valve(s). ❑ Shear Valve(s). ElDispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser-ID: Dispenser I D: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 4 Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s) *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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,l have also attached a copy of the report;(check all May applt): GiLsy tet ti lrm history report Technician Name(print): ►w /v"M $ Signature: — Certification No.:— 803 72 5,Zy; 33 2.`� UT 11 3 License.No.:_677:1- 0- <04i -aal& Testing Company Name: A r-DA _ Phone No.: pop �9, - 6a Site Address: 7'® .Date of Testing/Servicing: Page I of 03/01 Monitoring System Certification A Results of Testing/Servicing