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Rug•:24 12 11:03a Elite IV Contactors 12094616342 P.3 Appendix Vi {Copies of Monitoring System Certification form and UST Monitoring Plot Plan avail, it ; at hitt #www.waterboards ca aov.j MONITORING SYSTEM "CERTIFICA "ION For Use By A#Ju*cfcttora Maamrnet:e State of Galifanf Aufhcirity Cited. -Chapter 6.7, Health and Safety Code; the 16; Divisi x 4 'ritle 23; California Code of Regulations This form must .be "used to document testing and servicing of monitoring equipment. A separat_ ;riification or report must be prepared for each monitoring system control panel by the technician who of, the work . A ropy of this nm must be provided to the tank system owner/operator. The owner/operator must submit a COPY of this form to the local agcy regulate g S T systems within.30 days of test date. A. :General information Facility Name: Site Address CIO ._(=-� t'iACiD >�. city: Facility Contact. Person: ODntard Ph" No.: MakeJhAafel,of:MorritouingSystem. [i!/c`f! $ Oma/ r DataofTest*r pricing: r—Iy B. .Inventoryof•EgkdpmentTested/(CO ted Check the appmErIaldboxes to Indicate specific equipment in ed/ssnricbri Tank 10: Tank ED: _ L - In -Tank Gauging Probe. Model: D In -Tarn Gauging Probe.. Madel: Annular Space or VauILSr. Model: ❑ Annular Space or Vault Sa is :. Model: P#VSumpITrerch Sensor(s). Model: P a F Sump,/ Trench Sen: or Model: , - C Mechanical e han cal Uno!Le Model: d' FO SumP:Sensor(s)- Model: �h►+✓ ,E'' Mecliancal"i Una Leak_I)etector. fuodet . : ❑ Mechanical Line leak bete �t Modet: C Elect Ic Lina Leak Detector Model: 0 Electronic Cine leak Detecl or Model: - C Tank Overlgl t High -Level Sensor. Mod: D Tank 4verftl:l Hkjh•d avet S 3r .1r. Model: :C,. 'Oilier.. s ree a ui nnt.t a and model in Section E on Page �'_..� U. other s equipment tv �s .k model hs Section Eon Pape 2). Tank 1D: ° Tank ID: _ r. In -Tank Gauging Probe. Model:n Jn Tarn Gauging Probe. Model: i' "Aeurutar Space or Vault Sensor- Model: u Annular Space ar Vault Serra Model: C PgiinWSump t Trer ti'Sensor(s): Madel: ❑ Pipfi4 Sump.% Trench Sarm Model: C: Fitt Sump Sensor(s). Model: ❑ Rti,Sump Sens qs .. Model- C Mechanical tine leak Detector. Modal: 0 Mechanical Line Leak Deteclo Model: . C Lim Leak Detector. Morel: 0 Electronic Line Leak Deteck r. Model: C. arils verfdta {ighttavgt:Sensor. Model: 0.Tank:0vstfitl Nig> LevelSFn :r. Model* . .. L - .Dispenser Coni C . SWar, Velvets). C :. DisE9nser Cort DP enserrr- urspenserIa: _3 :r Dispenser CorstaInment Sen: a Modal:_701-y—, ❑ Shear Valve(s). sp Disi?�er:Containment Sersor(s). Model: � nrspert�r rD: 0 DfsperisarCbntairsneraSensor:}. Moiei; "Floats and Chains . [.� SidChaln(s).p.tlseu tD: Dispenser ID: Conta hent Sensctt(s). Model: Q DispensarContalrmsentSene:+r(,; Moo l:Shea!`.VEdv*)..: _. . SVahr2(s).. _. _ _,-moi Y,n.,.��...,.._•....a�..As..�«.1�. „-�rs+wi��—_-=.._._-_ H the facriity_contains more tanks or _._ _ _ ,. ,"copy this form. lndude infonrration for ay.. tank and -dispenser -- _ - _ p!Y _ penser at :e facility_ _�--C i`arufr�+l•,±+ Pify_ihat the equipmeaiJdenttPred.:tn_t>gdoartroentsvas -inspectedlsarurced, n. r:corxiance.bsrfth_the-rrreeiufacturers' gtddelirnes,,-Attsghed to tftls.Cert tion Js,Igfbrmaiion.(e.g._mantdactmm. cbeck6sU);n ry.n wify.that ,this informations is correct;--- atxi a plot Man shrnming the layout of monitoring equipment Fora►ryegfsipment•capafle of general in. uch re=ports, t have also attached. rnPPr�r /tom r?lthfsftsy r4pont— - ---. _ Technician Nam. `//•. _ Signature: j -- /V CertificationNo.� -,- --- . Licerne..ldki ..QG7Gt :..A�1 ! � _i _ _ ._.. _7estusgGom nYName '. Phore_No.:(� Testing Company Address: 95 " <" Date of Tasting .4NVk:ing Monitoring System Certifirmtlon . --. .. - --- ..... flag. 1 of 4 __....._ _ ._-.... 12107 . 1 2/21/07 e e 6 d