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For Use By All Jurisdictions Within the State of California Authoriti, Cited: Chapter 6 7, Health and Safely Code; Chapter 16, Division 3, 27de 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A senarate certification or report must be prepared for each monitoring 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: Q w cZ £ . Bldg. No.. Site Address: QS -7 S �C. ,QB&A-® L� City: �p Ry .2 b 5` Facility Contact Person: /Islf1. -4,&j e. h% Contact Phone No.: (Za�w7_ Make,/Model of Monitoring System: _r11_5 __30 p Date of Testing/Servicing: / 09 B. Inventon, of Equipment Tested/Certified Foto c ai.4 ?- Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: kS-M 10A4 'f1 Tank ID: j2d4g�p e 7 jR Probe. Model: EV ST 42- b2 T rZ In -Tank Gauging Probe. Model: ? 3 (1 •-/ bq R Annular Space or Vault Sensor. Model:.g 12S- ❑ Annular Space or Vault Sensor. Model: ® Piping Sump r Trench Sensor(s). Model.: Piping Sump 1 Trench Sensor(s). Model: �� 9 -.7�7— ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [� Nfechani2al Line Leak Detector. Model: 2 aft n g Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill! High -Level Sensor. Model: ❑ Tank Overfill i High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump l 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Levet Sensor. Model: ❑Tank Overfill! High -Level Sensor. Model: ❑ 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(so. ❑ Dispenser Containment Float(s) and Chain(s). [] 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 tate 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 equipiltent. For any equip nt capable of generating such reports, I have also attached a copy of the report; (check all that apply): tZSystem set-up VALI'srm historye�olrt _ �� ,t 7-40,, .r By ® t; c�z�. Technician Name (print): ®,I6 5U, �G�t1� �/t� Signature Certification No.: l teens . %: Testing Company Marne: iQ 6S Phone No.: (2a 3�7�- Testing Company Address:.�3 Ta �-G�a1 p Ctrt4 GCci C �- Date of Testing/Servicing: (;N-036 - IA Page 1 of 4 vw w.unidocs.org Rev. 01/17/08 Cd tZt,9-L9C-60Z %VOL 60 OC pea