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Sep 17 09 02:10p Elite IV Contactors 12094616342 P.1 <br />MON1100RIXG SYSTEM CER TUIRCATION <br />Fer (!s,, ' <br />,luthorip Cited: Chapter 6.7. Health andSaj,-jv Code. C-haprer 16-Divisim J. 7-jile 23. Califorwea Code or R <br />' u gea ons <br />This form must be used to document -testing and servicing of monitoring equipment. if more than one <br />monitoring system control panel is installed at the facility,-ificatio U for <br />91 e2oll MUt <br />1=1 Rancl by the fechniei= who performs tb6 work. A Copy of this form must be <br />pro;vided'lo the tank system, owner/operator. the owner/op=tor must submit a copy . of this form to the local <br />agency regulating UST systems.widiin 30 days of test date. Instructions are printed on the back of this page. <br />A. General Information <br />Facility Name: Bldg. No.: <br />s 25 A iz'f Cory s. ie CZ j ziw. <br />Facility C013mct P== Contact Phone No.: <br />Make/Model of Monitm* S*uc= Date of Tesfing/ServiciDg: <br />S. Inventory of EquipmentTested-lCertiffed <br />miate boxes to tntlicate m!ptnent Inii <br />Cleck the mme <br />oetWserviced: <br />A' <br />Tank TD: -7 <br />Tank rD:--SS <br />0 to-Twk Ganging Probe- Model: <br />13 hi-Irstnk Gaugn Probe. <br />Modek <br />30 Annular Spur W Vault Sensor, Moftk 3 <br />0 Annulm Spa= or Vault Sersor. <br />Model: <br />X piping $wWrmna Scnwr(s). Model: <br />0 Piping Surn;WTr=ch Sensor(s). <br />Model: :Zo4• <br />a Fill S" Sensot(s). Me": <br />Fill StuffSemr(s). - <br />Model - <br />.Pr Mechanical Line Leak Detector. Model: 1Z,;'. <br />.0 <br />U MechaaicO Line Leak Dc=or. <br />Model: <br />13 ElecooW Line Leak Defector. Model: <br />0 Electronic line Leak Detector. <br />Model , <br />0 Tank Overfill I H%fi4_cvid Sensor. Model- <br />Q Tank Overfidl I digit-Ievel Sensor. <br />Model: <br />onispeaser Contain n 1 San"s). Model- 14 i.o <br />0 Djqpwwr ContauupeAt Sensor(s). <br />Model: <br />0 Shear Valve(s). <br />a Shear vaive(s). <br />0 Ditilmoscr Cantainnum Floa0) and Clutin(s). <br />12 Dispenser Conatiument Tloat(s) and Cbazn(s). <br />0 other utrsmettttype and modeJ in Section Eno Pa <br />a Other (speciujnt = and <br />model in Scction E an Pate 2). <br />Tank ID: y I <br />Tank M� <br />0 is -Tank Gauging Probes <br />Model: <br />0 In -Tank Gzagiag Probe. Model-. <br />0 Annular Space or vault Sensor. Model: _4e ­(T_ 0 <br />Q Annular Space or Vault Sensot. <br />Model: <br />.0 piping-Samp(Trench Seaaor(,} Model: <br />0 Piping Sump/Ticach ScasWs). <br />Modd- <br />Q Fill SumpSaLsor(z). Model: <br />a Fill Sump Sensor(s). <br />Model: <br />0 Medianical Lim Leak Detect". mo&i: <br />0 Mechanical Line Leak Deteaor. <br />Modek <br />0 F-lectromic Une Leak Ckseetar. Model: <br />0 Mecrrouic Line L6k Detector. <br />Model - <br />10 Tank Overfill / High-Uvd Sensor. Modd: <br />13 Tank Overni I! High-L&v*1 Sensor. <br />Model - <br />,t Bispertttt Con Seraw(s). Modd- <br />;KI)ispenserCon I taitunent sensor(s). <br />Model: Item., <br />Cl Shear vaive(a). <br />a Sherr ValvCK <br />13 D*=u= CORWIVIUM F101093) and ClWn($)- <br />0 Dispenser Contaiinuent Flou(s) and Chain(a). <br />I C1 Other ($occify equiptnew rype and model in Section E on Pa .21. 10 <br />Other (EE!Ei 3pL=t DM and <br />toodd in Section E on E!r6c 2h <br />C. Cerdficaiftn - I certify that the equipment identified to ft documesit was inswted/terviced in accordance Witk.the''... <br />to this Certillcation, is information (eg. autnufactarew check1hts) necessary to <br />verify that rbis-inforumdon Is correct and a Site Plan7 showing the layout of.moidioring equipmeaL For any eqtzipment <br />c . apable X.copy ®f i>gi 7ch alCtiraiq, ®apsicta <br />repo"; <br />O Alam history report- <br />Technician Name (print):V'? No.: a2l, <br />Tes =-g company Name. <br />cnxrt os ft <br />, 7 <br />REC' <br />it <br />RUFFM <br />SAN COUNTY <br />HEAUFH CV-7PARTMENT <br />