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MAY 08 2003 8: 55AM _HFgK_ASERJET 3200 P. 1 <br /> vv rir In F I-QUK rWl <br /> tiz <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By Ali Amij&crions Within*9 State of California <br /> Aurharity Cited.,Chapter 6.7,Health andSqkty Code.-Chapter 10,Division 3, Title 23. California Q40 of Repilations <br /> This form mum be used to docs, wm testing and servicing of monitoring eciuipmeat.,&MjMN SIdia"UM 2 <br /> r2l mArna system,.ftfttM1 nffil by the techakian who perform the wo& A copy of this fo=must be provided to the tank <br /> system(.wucrloperator. The owmr/Weratar must subm;it a copy of this form to On local agency repiatIMI UST systerm,%itbin 30 <br /> days of test date. <br /> A. General Information <br /> Facility Name: Bldg,No.: <br /> sire Address: ZAQ City: oze-rzk Z*. arg-64 <br /> Facility Contact Person; Contact Phone No.: -71 <br /> M4ktftgdel Of Monlitorix Date of Testing/Sm icing: <br /> B. Inventory of Equipment Tested/Certified <br /> Cb"k the soprepriate bozos zo Indicates enact to ted: <br /> Tank ID: Tank JD- <br /> Z In-Tank Gauging Probe, M946 0 irin-Tank Cauift Probe- Modt. 0Bq7574aj-/0j <br /> RrAnnular Spwc or Vault Serwr. Modcla 7 aAnnular Space or Vault Sensor. Modal: 072 9 <br /> Vot <br /> WPipiq Sump!Trench Sensors Model- 127"IrdfS yf) 2?ipirg Sump I Trench Sensor(s), Model: <br /> U fill Sump Sensor(s), MOW: 0 Fill Sump Sensor(s). M06-t. <br /> 0 MevhanicFl 4imL Leak Detector. Model. 0 Mechanical Line Leak Detector. MQdii- <br /> 0 Electronic Line Leak De*t*T. Model- D Electronic Line L*&Detector. Mocl'4: <br /> 0 Tank Overfill I High-Level Sensor, Modcl: U Tank Overfill/Hijb­Level Stator. Model: <br /> 0 Queer(SRSSjUau=t typrmul model in SeCtJW Boil, _Q Other(sWiry0Qu4m*At1yLKWW model in Section E onpaje2). <br /> Tank ID: tI— Tank 1D. <br /> Ar Jn-Tank Gauging Probe. Mode# 0 4n-Tank Gauging Probe. Modell <br /> Annular Spacc or Vault Sensor, M 0 Annular Space or Vault Sens M <br /> jaTipinil Sump/Trench Scnsor(s� N 9 Piping 3urnip I Trench Sensorl(�151 .mr <br /> 0 Fill Sam Sensor(s), 0 Fill Sump S IN() Moditt. <br /> 0 Mechanic <br /> 11 Mechanical Line Lo,Detector. Model. W Lint On or. Maditi: <br /> I <br /> *Mor"" <br /> in <br /> (3 Electronic Line Leak Detector, Model: (3 Elem "'�L�Lexk Detm"wvvtor- Mod:l: <br /> "Zon <br /> `eL <br /> * T*nk Overfill/H igh-Ltvel Sensor. Model: (03 0111 High-Level Sensor. Mod.0. <br /> * Other(specif�% r e and model in Section E on P I- �Eer LW mod I in Section E on?a <br /> est <br /> Dispenser ID: Dispenser ID: <br /> ,W Dispenser Containrnct�t Sensor(s} Model,T2 & <br /> 0 Dispentser Containinent <br /> Wshmt valve(s), Wshcar Valve(s) <br /> Cl Dimstr Containment Flow(s)and Chains Q Diu=&16iflmenr Flows.)and Chain s1. sl <br /> Dispenser JW. <br /> Dispenser ID: - - ------- <br /> on <br /> 0 Dispenser Containment 5ensor(s). Model; Cj oismstrcontalnm"�Ontsc ��M <br /> Containment <br /> ), n, <br /> r Comi <br /> 0 Dispcnw 2Lmtainment Flegs)and CL9�s- i;mcnr F!egs and C <br /> r Com and Chain(s). <br /> Dispenser 1D: Disperser M. <br /> C3 Dispenser Containment Simsor(s). Made DiwnwCoratainment S -_jW <br /> C3 Shear Valve(s) D Shear Valve( <br /> E3ntainment AD <br /> 0 ws)and Chaff!g!j, omainment Figgg.and ChaimIll <br /> off the facility contains mcort tanks or dispensers,copy this form include infornation for every tank and dispenser at ft ftlily. <br /> C. Certification-i certify that the equlpment Id"flM In thisileawmt was In serviced is accordance with the manufacturers' <br /> guidelines. Attached I**ls Certl0cation IS Inforalittin(&g. manufacturers' cheddWS)XMICOISSfy 10 vertry that this information is <br /> correct and a Plot Plan showing the layout of molsilloring"went. For say equipment capable of gentrating such reports,I have also <br /> stacbtd a copy of the report*(ch I eck att rh grSystam set-up &A-larm history report <br /> TecWcian Name(phot): (,,,!g 4 <br /> certificalionNo.; License.No.: 92314 to <br /> Testing Company Nam: Sto&tca S C+.+4-. iru— PboncNo,-.UAL_X 464 , <br /> Site Address: Date ofTestinoeMcing: <br /> Page 1 of 3 *At <br /> Monitoring System Certification <br />