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1I0\TIT Zl\ G SYSTEM G E RTIC' `-' 4TION For WBv Al/ Jurisdictions Within rh OfCn. .i hpter 6.7. Health and Safer• Code; .•l uthorirt- Cited: Ca Chapter 16, D:.:sior ?. Title '? California Corte of Regulations This form must be used to document testing and servicing of monitoring==uipment. Ase^grate cenification or report must be rreoared for each monitorinc s%-stem control panel by the technician who..--~s the we-'s:. A copy o this form must be provided to tl:e tank system owner'opera:�r. The ownen'operator must submit a cop, c: ....: form tc ,..: local agent} regulating UST systems ;within 30 days o; test date. 9 A. General Information Faciliry Name: JOAc-i-E't e P��VD4 Bldg. No.: Sire address: 5 61 t rt,' F �CKK. C:-. D D ; Cd' Zip: Faciliry Contact Person: Contact Phone No.: ( ) �fake;tilodel o.``Ionitoring System: G��/�GG .44-,tV_ L,4,-0§ Da:e c. Testing Servicing: 12/ `15 / a 1 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected%serviced: Tank ID: F-F- PZ041) P,C_Sz:2L Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gau_ino Prose. Model: nr.ular Space or Fault Senso-. Model: 4_A-LS-1 ❑ Annuia- =pace or Vau : Sensor. Model: fr`�iping Sump i Trench Sensort.$). Mode]: L +(-5 -1 ❑ Pip,in?_ __-p %Trench Se scr(s). Model: .1 -::I! Sump Sensur(s). Mode]. .. ❑ Fill Su: . 3'%lechanicai Line Leak Detector. Model: 1/t= —nt-7 ❑ Mechanical Line Leak Dt=.tor. Model: ❑ Electronic Line Leak Detector. Model: ❑ E1ecn, en._ Line Leak De.-Cc: or. Model: ❑ Tank Overfill i High-Level Sensor. Model: ❑ Tank O•• e-flll / High-Leve: Sensor. ,Model: ❑ Other (specify couiprnent t..-. and model in Section E on Page 2). ❑ Other (s. fv eauic:^ :,.7e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gau^int Probe. %lodel: ❑ Annular Space or Vault Sensor. Model: ❑ Ar.nula- S_ace or Vaui: Sensor. Model: ❑ ?iping Sump / Trench Sensor;.$). Model: ❑ Piping S _n-p /Trench Senso-(s). Model: Fill Summa Sensor(;). Model: ❑ Fill Su--. Sensor(s). Model: :1 Mechanical Line Leak De.._o^to:. Model: ❑ �Mechan.c_: Line Lea, De..c:or. `fodel: Electronic Line Leak Detector. 1:1 Electronic ❑Electronic Line Leak De:ec:or. Model: ❑ Tank Over,•":ll / Hich-Level Sensor. Model: ❑ Tank O• e: "il / High-Leve: Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑Other (s_ecift eauiprre::: �qe and model in Section E on Pace 2). Dispenser ID: Dispenser ID: D Dispenser Conmir,mcnt Sensor(s). 'Model: ❑ Dispense- Containme-.: Sensor(s). Model: � --I Shear Valve(s). ❑ Shear Va:•. e;