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Work Order: 2243602 111�III Jill III III MONITORING SYSTEM CERTIFICATION For Use By AllJurisdicfiom Within the State ofCal fOrrrta dw0wity Cited.-Chapter 6.7 H=11h and S*ry Code,Chapter 16,Division 3. Titir 23,California Code of Regulations This form must be used to do Hien testing and servicing of monitoring equipment. A se orate Certification or tetmr4 must be RrcFared for each nitorina skstan eontr 1 Vane by the technician who performs the worts. A copy of this form must be provided to the tank system owner;operatar. The ownertoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneralInfo tion �j Facility Name: `C3 BtdS.No.: ( Site Address• City Zip: Fatality Contact Iverson: Contact Phone No.:aijI MakidModel of Monitoring System: — Data of Testing/Servicing: �LIAJQeb S. Inventory of Equipment Tested/Certified Cheek she opproprote boxes to iadirzu speeltle eq ateat taspcetedyervigd; Tank ti): Tank M- 0 in-Trask C*anging Prof Model: __ 0 LrTsnk Gauging Probt, Model: C1 Annular Spam or Vault Sensor. Model: O Annular Specs or Vault Sensor. Model: 0 Piping Sump I Tratch Sensas(s). Model: 0 Piping Sump/Trmcb Scosoor(s). Motel: 0 Fill Sump Sansor(s). Model: _ El Fill Sun* z), Model- 0 Mecbmirel Line Leah Detector. Model. 13 t it chanical Linc Lads Detector. Model: 0 Electronic Line Leak Detector. Model: Cl Electronic kine Look Oaectoc Model: Ll Teak Overfill I High-Lens!Sensor. Model: O Tank Overfill I Higb-Lavel Sensor. Model: 0 Other( ant type and model In Section E on Page 2), 0 Other ty oqttigmeid and model is Section E on Pate 2). Tach ID• Tank IV: 0 In-Tank Gouging Probe. Model: 0 is-Tank Gonging!robe. Model: 13 Annular Spon;or Vauh Sensor. Modal: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump l Trench Seusm(a}. Modal: ' D Piping Sump l Trench Sensor(s). Modal: Sump Srasor(s). Modal: p Sestswo). Model: _ Cl Mechanical lino Leak Demeter. Model: 0 Mee>a nical Lina LeakDet+xtos Model: electronic Lisle Ltak Detector. Model: 00 ectrunic Line Leak Deteckw. Model: 0 Teak Overfill f High-Level Sensor. Model: 0 Tank Ovr+flll I Ell h-1 evol Sensor. Model: 4 Giber(specify c moat(yr and model in Section E on Page 2). 13 other(a—*cquil-law type and model in Section E on Page 4 D(apottaer ID: Dispenser IRs: 93 Coaulmocat Scumn[a). Model: 0 Diaponsor Containment Sensoros Model: O Shear Valve(s). O ShearYstva(s). 0 A!Mscr Containment FICKS)and c hnia(s). D Dbpmw CotdainatcM FlorAs)and Chat s Dispenser 1Rk Dispenser ED-- 0 _0 Dispenser Caatainmeru Sensor(:). Model: ®Diapetsca Containment Scust"o). Model: Q Shear Valve(s), D Shcar Volvo(t). d MWasm,Comair ncM F125s}and Chaiu(s� CI Ais er Cmntaimucat ftol(!2 and Chs%s). IKspewer ICD: Dispenser 1111- 0 Dispenser Cvntaboncm Sensor(4 Model: 0 IIispenser Conlabi tett Sensvr(s). Model; O Shur Velvets). (3 Sbaar Va14c(s). ODi Haff Containment FkwKs)and Chein(s). 0 Di cr Contaimeent Ftual(s)and Chwu(s). •If the facility contains nwre tanks or dispensers,copy this fbrm. 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'guideline. Attached to this Csrtifaeatiou in information(e g.manufacterers'checklists)necessary to verify that this information is correct%a I'lot Plan showing the loyoat of monitoring equipment. For any equipment capable of generating such reports,I have also attsaged a ropy of the report:( k aft these applj+): (3 S et-up D Alarm hlstoty report Tach. {� h tR d' Qip�ire - Certification No.: {AALicense.No.: Testing Company Name �,�"� � t t®tt_ Phone No.:�� r Address: DW&of Testingrmtvicing: Page 1 of a�pf Tanknology-NDE 8900 Shoal Creek,Building 200 Austin,Texas 78757