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No- 14 12 12t36p Elite IV Contactors 12094916342 p. 2 Appendix V1 .(Copies of Monitoring System Certification form aril UST Moriitdring Piot Plan availabl !tt help:/lwww.watet991ds.ca.aov.) MONITORING SYSTEM-CERTIFICKON For Use By AllJur{scGctfona Within the Since of Catifonrl< Authof*r Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Divisibn i,Title 23;California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separat: c rlificadon or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of thft f rn must be provided to the tank system owner/operator. The owrw1operator must submit a copy of this form to the local agency regulatin t t _T systems within.30 days of test date. A. .General Information Facility Name: {{��/n�1 tdg.No.: r a SEteAddne :-_�_-10I �� tCIQ _City:' _ --bp: Facility Contact.Person.,<. t� Gontad Phone No.: Make/Modsl of:Monitaing System: /&,C/%'-/.V/ ( .3 Sc� Date of Testing S. n Egag: / / _.. S. Inventorypf•E-cjufpment Tested/Cdidfiod Check the ro "ateboxes toIndkate 'fic uE rnertt ins ed/serviced: 1� TanklD: ' Tank[& _ _ L-In:-Tank Gauging Probe. Model: it In-Tarso G�ai4ng Probs. Model:- kf Annular Space or VadtSensor. Model: 4C'S ,jar Annular Space or Vault Ser I Model: O Piping.Sump/Trench Sensor(s). Model:. ^ Pipfng3urnp/TrernchSenior ). Morel•" � C Fill Sump`Sensor(s)_ Model:__. . _44i Fill Sump'Z ensor(s). Model:_ v Mec hanical'Lina Leak.❑etector. lNatek " /'.°'cCC) jef Mec hanrr�l Line Leak Dete:h Model: z Bectionic Lki Leak Detector. . Model: 0 Electronic Lime freak Detect y.% Model: . C Tank Overfill/Fligh-I-evei Sensor. Model: 0 Tank overNJ High-level Sm 3. Model: C 'Otterr LsR2cffy!qgment ty0e and model in Section E on P2M M. 0. Ott erg pP !id model re}Section Earn Pa 2. TWO: Twit ID.- 'r.,In-Tank Gauging Probe. Model: n In-Tank Gauging Probe. _ Model: _�L' Ann"ylar$poo a or Varrlt Benson. Model: " U Annular$paoe or Vii sf Sen 30 Model: -C --Shrike/Trenc h;SenSa'(s) Model: ❑ Piping Sump,/Trench Sensor( . Model:. c: FUI Sarrnp Sensor(s).•. Model: D RI.Sump Sensors).. Model:. C Mechanical Lire Leak Detector. Model: 0 Mechanical Line Leak Delecto Model: C .E{actrorsc llne Leak Detector. Model: 0 Elactronic4 ine Leak Detect:r. Model: t*:TapkOverflil/-L!)ghsLevel,Sertsor. . Model: 0 Tank-0vodli1Migh-Levei:S�n; r. Model: C.Other Kpipment and model in Swfion Eon P e 2. 0 Other snot t e. Id Model in Section E on P 2 Ong rID a Z . , ` AfContainment Senso(s). Model: 7.4 e-Dispenser Containment Sent v, a;. Model: CF C .Shear.Valve(s). � 0 Shear Velve(s). C:.die Canaainm®nt Ftaat s and Char s. p D riser Contairvraerd Floa fs end Chainfs. dia:pertser ID: , Dispenser ID: :C.:Plslxm.cr'ContainmentSensor(s). Model: ❑ Disp rCiirrtainmentSen:or :j. Madel: C :Sti®ar:value(s). ❑ "VaWs). 'G.:::D Co ntainment'F at sl.and Chains. 13 dais r r-Con ainmi3M Float's' r id Chain s ;D.- C Dispenser Containment Sensor(s). Modal: 0 Dispanser.Containment Serer�r Model: L..:SheatcVwo(s).: U Strear,VaWe(s.. tainmentA _arni Chain -, 2 a. taft'merrG=Flaa1+ nrL haln s.-- �:._..� ll the :_ contains more tanks or disp9m rs.copy this torm. Includsinformatioa for every lards aro-dispenser a hs faculty_ ___._._� r-Rrttttcat�rr=r crarttfv�n�ar sree�t2 - enfitied.:ir�_�s�cfacu s :-iii a�r�race�nrttti-�.medarfaceirrera'------ -_._. grltctalirres..;.. d;ta,firs.Gerflfir tion ls'ferfattvratlon.(eg.ananufactur�ew cbeckosts) to n:rPly.that:ids3rdorrrration3s corr�t. pro a I'+tot Alan showing the layout of monitoring equipment. For any equlpment.aapabhe of genera In Ruch rep6r1s,I trove also attached a F-tf� f+Qrtr-�c�tl3a ��--=@..., -spat pT-Q-Atl9rarr�fist+my-tBport - -u Tsctirtician Name Signature: 7' ! Ceatatlan No_: ,... .........._.__.._......._.. license.Na.: "Tsstlag-Can�any Name:. _ m- Phone.tda(Ze'g ) (a.LJ I. Testiisr Cotnparay Aoklte�: t-, date of Testi nr 3 anricing: 8 !/fir/C Monitoring System Carni Page 1 of 4 12107 2/21/07 b e b J i