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SYSTEM CETION For Use By All Jurisdictions Within the State of California ,,r 4->toivijy Cited_ Chopp) tS 7, Health and Safety Code, Chapter 16, .Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipxneaat _; . n arrd fo each monitorig syagrn control by the technician who performs thew of tini forma 'ded to the tank system of nerloperator, The owner/opemt�or mast submit a copy of this fortes stems within 34 days of test date. A. General information SEP 13 2 , Facility NameICtnJik SMVE Bldg. No.: Site Address: 2SPI .SA�k N City. g 5 C9cd'u ? UNTY Z_e kL S�:;i v1Facility Contact Person: Contact Phone No.:j� Make/Model of Monitoring System �'Gs 3'U Date of Testing/Servicing: , . q / q! -O B. Inventory of Equipment Tested/Certified check the apuroodatc boxes to indicate specific serviced: Tank )OD: Tank ID: B Ira -Tank Gaugiaag Probe. Model: Tn-Tannic Cx�tgatag Pz9obe. Model: it Annular Space or Vault Sensor, Model: " v Annular Space or Vault Sensor. Model: UL Piping Sump / Trench Sensor(s). Model: 'les& $( Piping Sump / Trench Sensor(s). Model: Zd ❑ Fill. Stunp Sensor(s). Model: ]2). ❑ Fill Sump Sensor(s). Model: 5k Mechanical Line Leak Detector. Model: M Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q,Tank Overfill / High -Level Seosor.Model: FAL Of Tank Ovafill / 1-Tigh Level Sensor. Model: tf![Q Other s eci ui ment and model in Section E on Pa❑ Otho ui ent and model art Section E on Pae 2). Tank ID: St Tank ID: ❑ InTankGauging Probe. Model: 1A in -Tank Gauging Probe. Model L{it� ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 5L Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Treaach Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 4 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: - -- ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C% Tank Overfill / High-level Sensor. Model' �t _ ; M ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other c' equipment and model in Section'E on Pae 2 . ❑ Other i ui t and model in Section E on Ps e 2 , Dispenser iD: Dispenser IGD: ❑ Dispenser Containment Sensor(s). Model: � ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). JO Shear Valve(s). d -Di enser Containment Flops and C s . tX Containment Floa s and C ' s _ Dispenser ID: Dispenser ID: ❑ Dispenser Containmeat Sensor(s). Model:_ ❑ Dispenser Containment Sensox(s), Model: ❑ Shear Valve(s). ❑ Shear valve(s), ❑ DiERenser Contaluinent Floats and C s ❑ Dispenser Containment Floa s and C s . Dispenser ID: N Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valvc(s). ODispenser Containment Floa s and C S).---- ❑ Dispenser Containment Floa s and Chain(s) . *If the facility contains more iarft— or dispenzem, copy this form include information for every tsnk and dispenser at the facility. C. Certifieation - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (ag, lttmanufactur+ers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attache a copy of the rt;drerk' all that q*): stem set-up WAla t history import TechnicianName (print): C)ft0 P N� Signature: t`- CertificationNo.: 13V;?T3 License. No.: Testing Corrmparry Name: = 'ir LL Sfi2v�� PhoneNo.: � qqN nu Site Address: �Sr�50-' n4%fA/ Date of TestinWSeavicing; I l�' OWN Monitoring System CerWrcation