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u RECSE�'WfiDIJPFORJNG Sir CERTI_ .ATION l �r IZse 4v All Jurisdictions 14 Whin lire Sieae of C'a rforrrin Azahoritv,C'Ye er 6.7. Hecrllh cvul Sgfeln C.'otle; Chcq.7ter 16, Division 3, Title 23, Ccrlifbrnicr Code gf'Rc�,>ulnliurzs MAYb ift� This forni must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepareff mi,ekch.'M&RAA lum control panel by the technician who performs the work. A copy of this form must be provided to the.tank s Ni))rRwi R • The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: /LLS A& Bldg.No.: Site Address: 3 f '1�BGToe City:_4¢b/ Zip:X52 O Facility Contact Person: Contact Phone No.: (_Zo 9 ) ,�(p� - / s Make/Model of Monitoring System: ya 7 1S 7-50 l Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the approeriate boxes to indicatespecific a ui ment inspected/serviced: F)WFII' nk ID: a,c---r Tank ID: GT In-Tank GaLlg;ng Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model J�-Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model• O _ A Piping Sump/Trench Sensor(s). Model:Fill Sump SenS01•(5). Model• ❑ Fill Sump Sensor(s). Model: 19 Mechanical Line Leal:Detector. Model: ZO ALMechanical Line Leak Detector. Model: GK' ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment ty a and model in Section E on Pa a 2). ❑ Other(s ecif a ui ment t ie and model in Section E on Pae 2). Tank ID: 5 CT ®G"T Tank ID: Rd In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: J4 Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model ILPiping Sump/Trench Sensor(s). Model: W rl ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model:�—� ❑ 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(s ecify a ui ment!xEe and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: -i-Z_ Dispenser ID: -f- Dispenser Containment Sensor(s). Model: o l0 14 Dispenser Containment Sensor(s). Model: CM, Shear Valve(s). A Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: 'fid- Dispenser ID: )d Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Ef Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: sem{-40 Dispenser ID: 4 Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: A Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s)l "If the facility contains more tard,:s 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 equipment. For any equipment capable of generating such reports,l have also attached a copy o�fl the report;(check all that applp): USy to it arm history report Technician Name(print): tVir AhSignature: fiCC 526 33a-7 07- Certification No.: /�/ � License.No.: d" -/0 71, Testing Company Name: A Wor p,4 s r Phone No.: ) rj-h/ - D//'.2° Site Address: /GT® Date of Testing/Servicing: Page 1 of3 03/01 Monitoring System Certification D. Results of Testing/Servicing