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1925551788q Main Fax GETTLER RYAN INC 10:51:06 a.m. 07-13-2007 2/15 is MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorin system 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 date. A. General Information �® Facility Name: C, C / ,C,,, / Bldg.No.: Site Address:, i 2 3!f c+�'►• �c t City: i t�t- r e.- Zip. Facility Contact Person: Contact Phone No.:{_� Make/Model of Monitoring System: yc®t'dv Coo 7� 7Z 4 3 VV Date of Testing/Servicing: 6 / Z Z/ o} B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: [03 nk ID: "7"1 : S�si�rew►t Tank ID: TZ 'in-Tank Gauging Probe. Model: g Y 3-i'Q t®? In-Tank Gauging Probe. Modal: f V6 3 S 0- /02 Annular Space or Vault Sensor. Model: �9`/3q O- yd�` Annular Space or Vault Sensor. Model: �y 3 S O-Y01 Piping Sump/Trench Sensor(s). Model: +41 Y 380- 7-0 XPiping Sump/Trench Sensor(s). Model: -+07 Y 380 - Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: ,(Electronic Line Leak Detector. Model: 'Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: O Other(specify equipment type and model in Section E on Page 2). O Other( ' equip meat ty e and model in Section E on Page 2). Tank ID: Tank M- 0 In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor- Model: O Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: y�O Z ds Dispenser Containment Sensor(s). Model: 21Y J S0- 2,4 P Pt Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment FlOat(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenter ID: S 4 fm Dispenser ID: -Ntn -3- ispenser Containment Sensor(s). Model: 1-9Y38a-- 7-0? Dispenser Containment Sensor(s). Model: -49Y390-24? EisL=nser hear Valve(s). Shear Valve(s). Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Floats)and Chain(s). LP Dispenser 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 verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any a uipment capable of generating such reports,I have also attached a copy of t e report;(check all that apply): X:yst! ystem se p Alar history repot Technician Name(print): 4C—to 4- t- u�c 5;e,w' e-4 Signature:--- Certification igna Certification No.: 3 d / 3 d� License.No.: 2 20 7-q-7 Testing Company Name: �e. ��— 25�^- �-� �— Phone No.:( -7 Site Address: Date of Testing/Servicing: ZZ/ -0 Page 1 of 3 03/01