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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the $Fate of California Authority Ched• Chapter 6.', Health and Safety Code; Chapter 16, Division 3, Title 23. California Code of Re;ulations This form must be used to document testing and servicingof monitoring ication or Mort must be revared for each monitoring sysem control ganef by the technician who perform;_ -F _ fom2 must be provided to the tank system owner/operator. The owner/operator must sul trait a copy of this.mto the local agency re�aiating tST systems within -0 days of test date. A. Genera,? Information JAN 2 8 Z003 Facility Name: Z7ZgCi6I ��ee',!e �z a e� NVIROUMEN T HEALTH std,. No.:_ Site Address: T!zq_6 /A'Acy atclzx (jt�w jl ES Zip: Facility Contact Person: 1e Contact Phone No.: ( 20 5' ) 2 -, OOlr MakelModei of Monitoring System 6 4 ✓+cam lr^c Date o€Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea nate boxes to indicate flc . mead serviced: Ta IU: Tank ED !`� _� Thtik Gmging Probe. ?Vlodeh d °j ! Tank Gauging Probe. Model ! C? ! Q_ Annular Space or Vault Sensor. Niodel: f 666 An=w Space or Vault Sensor. )rTlodei L'1 Piping Sramu /Trench Sensor(s). efting Sump 1 Trench Sensor(s). 1,lodel FAff ' a ct t1 Fold Sump sensor{s). Model: ❑2j}7-'11 Stamp Sensor(s), Modak Mecham: ad Line Leak Detector. Modell: C 1Meehanical Line Leak Detector. Model;- odel:❑ ElElectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Ovedli f High -Level Sensor. -Model: ❑ Tank Overfill / Higb-Level Sensor. Model: ❑ Other (specify anent = and model in Section E on Page 2), ❑ other (sveci eciu' mens type and model in Section E on Page 2). Tank ID: 7 f2re we S"T, Tank ID: Y l'J �e �.s, ST` WIn-Tank danging Probe. Model: 1 0 t nrl�-Tank Ganging Probe. Model: 141 Qr,�knnular Space or Vault Sensor, Model: ROO 2 Cveyyaoo ("Annular Space or Vault Sensor. Ndodek e? � �� of ei4Qadi C"iping Satter / Trench Sensor(s). ' Model: P_A d 2 S!? 1&9? s to La'Piping Sump I Trench Sensor(s). Modes [� ta2S t!l�oed,rs 13 IW Sump sensor(sj. ech;u%ieal Lane Leak Detector. Model: 6 •- S_ U Fin Sump Senscr(s). Modch Model: Zf l3 Z echanica1 Line Leak Detector. Model• ❑ Electronic Lim Leak Detector. Model: C] Electronic Line Leak Detector. Model: ❑ Tank Oveifi3i /high -Level Sensor. -Model: ❑ Tank Oveafatt / High -Level Sensor. Model: ❑ Other (sped ipa�at and model in Section E on Pa a 2). ❑Other ( ui nt and model in Section E on Dispenses II?: 14 '2 Dispenser ID: _ 7'6 `! ❑ dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �Shear Valve(s).� ar Valve(s). is user Containment Floats) and Chain(s).. user Containment Float(s) and Chains) Dispenser ID: Dispenser ID: 7 `" iF ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Seasorts). Model: I Lt9'"Shear Valve(s). O -Shear Valve(s). 123rbis nser Con-' ent Floats) and Chain(s). Q' ksvenser Containment Float(s) and Chain(s). Dispenser. ID; // — If, Dispenser- Ln; Q Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: W -5 -hear �_ive(s?. ❑ Shear Valve(s). GOis enser Containment Fioat(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). u,by ...,,.ins uasxc L4mkb yr uaspcnsers. copy uars rosin. anetuoe intormanon for every rank and dispenser at the taeility. C. Certification - I eerti€y that the equipment identified in this document was inspeeted/ser vieed in aaccur4anee 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, I have also attached a copy of the repo { ick itf lh�u apply): Q System set-up Q histo[ re,�ort Technician Name (print): -- f �r'P7 t Signature: Certification No.: .912 y p_ License. No.: Testing Company Name: _ZR'f — Phone No.: (—Sao 4X0 — Site address:(� / 7� 1 3O rs �� C—_�," MI ?-:3jCt,f7 Date of Testing/Servicing: I_I Page 1 of 3 43/01 Monitoring System Certification