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OF SAP 11 12 11:00a Elite IV Contactors 12094616342 1 Appendix -VI (Copies of Monitoring System Certification form and UST Mon'itbring Plot Plan availabl at http;L%o �.watgrb2and s.ca.go MONITORI14G SYSTIEWCERTIFICiC ION SEP i 2 612 Far Use J9IyAlt Jvdsd7cffbns Within the State of CallforaA Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division, :,,,r1t1e23,'Cd1forma Code_of Regulation.9 This form must be used to document testing and servicing of monitoring equipment A siipamtv c Affication or 'report -must be prepared for each monitoring system control panel by, the technician who performs the work.. A copy of this; I rm must be provafed to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulatini ';T systems within 30 days of test date. A. General fr4brmation Facift. Name: 31dg. No.: Site gess: 3 r city.- dip: F Facility Contact. Person: ii.q rmir —Contact Phone I No.: L._ I _ /V ItVglel -AX ;�IS S-576' Dale of Testing IS i'cin MakelModel. of:Monloring System g: X14f4-1-7 E. Inventory of -Equipment Tested/Odilified Check the Mropdatabiixei to indicate sLqd�fla LxLulme I rat * ected1soviced: p M, Tankll): -37 Tank ID- L - In'Tank Gauging Probe. Model: U In -Tank Gauging Probe-, MOW:. e. - Annular 'Space or Vauft.Sertsor. Modek 4 ZM Annular Space *or Vault Se is Modal:' :c Piping Sump/ Trench Sensor(s), Modal: PipingSurnp/Trench Sent or Model-, C Fill SumpSertsor(s). Model: to Z. Fig Sump.Wsor(s). Model: Mechanikw 7 Lina Leak Detector. Made Made]: 1: -ViNI—L49e) Machanical Line Leak Dots zb Gledr6nic Une Leak Detector. Model 13 Electronic Line Leak Detec: or moclacAd Tank Overfill I fligh-l-evel Sensor. Model: ID Tank Ove4lj Wgh-Level S er or. Model: �C '0tftqr.M22t !M!pment. and model m- Section E on Page 2). D. Others !W!Pment tj p( and model In Section E. on Page Tank ID: Tank 113� r. *In -Tank Gauging Probe. Model: n In -Tank Gauging Pmba Modal: _C Arr".SpaqeorVault Ser=. Model, U Annular Space ersc Model: pr,YAOt S C 01*68unv / Trahch'Sersoqsy. model.. 0 Piping Stiftpl.Trench Sam. xi I Model: C Fig SLUM Sensor(s). Model: 0 Fdl.Sump Senscals).. - - Model: E Mechanical Line Leak Detector. Model: D Mechanical line Leak Dater Ic Model: -L: .Electronic Lim Leak Detector. Model: 0 Electronic Line Leak Detedor. Model: Tank-OveffiUSIgh�el; Sensw. --Madek 0 Tw.*.C)vjsrfig.I-High-Lovel.Stin, N% Model. ..e Dispenser Containment Sansoqs). Model: E . Shear Vaive(s). -C.:. CDnWmnW QcatW and ChainLsL_ 07 'e, V Dispenser W to or E C a — C C 's)" Dft D �Ir n Dlepenser.11), C:- Drigon.serContainment Sensor Model: --F---.pWanser-Con[Wnmat:Float(s) and ChaJn(s)- D _1113: Dispermier E r- Olt, Cont. Dispense p r Containment Sensor(s). Model: T "; contains, more tanks or- dispensers; this form. Indus Dispensm to: it or Containment Swim t). Model: a show valva(s). D Dispenser Containment Floe Is i mnd Chain(s), Dispenser 10, 0 101bor7., - c6r." ser npreant $ert;o Model: 0 ShisaarVelve(s). .0. Ditipersercontainmei*F16a(s; Di 1D: Q Disparraer.Containment Sensor :,1. Modal: it ShearYaws).. PM I =dIfy-tat-the-equi ent-Wentifled-InAhIsAocurnen -A (4ppow. ftac.he4, Ia.Ws..Cer.t.Iff="on Is informatkin.(eg. roanufactur :and a, Plot Man showing the tayout of monitoring equipmem For any eqi Tooftclen I Name (pint). Vii: )azl b/ Slgratuitr:. _CertIfica#on.No.,_. ..Ucense. No.: F Tes"Company Address: 21-2-22a 14 UZA tevery lana. ?W!q:01SP0nS0'8 I'StaCIBLY. was-frispected1swAced-Jr a' chacklisa),necessary _11C V arify. that IWs Information is -correct MWIt,capahiii of.genera tic ismh reports, I have also attached a Martor-'epart Date of Tasi in Monitoring System Certification Page I of 4 12(07