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MONITORING SYSTEM CE4 WHFICATION For Use 0), All Jurisdiellons Within the Slate of California flttthority Cited•- Chapter 6.7, Heolth and Safety Code; Chapter ib, Division 3, 7'ltle 23, California Code of Regulations This form must be used to document testing and servicing of monitoriq equipment. or{� kkaa-ea}o FxorattaFi ttttei-fll � nstnNet ti;y;-Lt_Q_s�r�te certifica ion or repo st be prepared for each n o tugs stent �o:tt o net by [h tetr�lriam tviu�et'fornx3 tha �vc►rk A copy of (hits form must be provided to (he tank system owner/operator. The owner/operator must submit a copy of this €o to the local agency regulating UST systems within 30 days of test date.-lristruetiens I' Iff-inte"1141 bnel�e Nais page ' ' Z017 A. General Information N Facility Name: j�alr 131dg�No;: " ' Site Address: j6g1 c�kfion._Aw City: L_E4CAion Zip: Facility Contact person: Contact Phone No.: _ Matte/Model of Monitoring System: T v2-3'�® Date of Testing/Servicing � ( B. Inventory of El quipment TeatediCertifxed .. 4.. F.......o fn in.r�nni> a nn��i� Pn..i».»an} InO., PI. FPIr IQPYVII�PIi+• u,ccn iic Al'f'a win _ Tank ID: g ryT Tonic ID: _ D In -Tank Ganging Probe. Model: © In -Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: D Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: D Piping Sump / Trench Sensor(s). Model: © Fill Sump Sensor(s). Mode]: D Fill Sump Sensor(s). Model: 14 Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill / High -Levet Sensor. Model: D Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). D Other (specify equipment type and model in Section E on Page 2). Tank ID: Tnnlc tD: D in -Tank Gauging Probe. Model: D In -Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: D Piping Sump / Trench Sensor(s). Model: [j Piping Sump / Trench Sensor(s). Model: D Fill Sump SenSV(S). Model: D Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill / High -Level Sensor, Model: D Tank Overfill / High -Levet Sensor. ModbL ❑Other (specify equipment type and model In Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID:` Dispenser ](D: D Dispenser Containment Sensor(s)_ Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D Shear Valve(s). D Dispenser Containment Float(s) and Chain(s). D Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D Shear Valve(s), D Dispenser Containment Float(s) and Chain(s). f D Dispenser Containment Floats) and Chn'sn(s). Dispenser ]ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D Shear Valve(s). D Dispenser Containment Float(s) and Chain(s). D Dispenser Containment Flont(s) and Chain(s), cif the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identified in this document was Inspected/serviced in accordance with the r Anufacturers' guidelines. Attached to this Certification is information (e.g, manufacturers' checklists) necessary to verify that tills information Is correct and a Stte--I'lot Plan showing the layout of monitoring equipment Yet- any equi rment capable of generating such repots, I have also attached a copy of the report, (check all that apply): system Set-up ' Ll Alarm hi tory report Technician Name (print): Anthon Leivas Sig Nture: Cel'tifif,ation No,: b43182 License, No. :� 8220961 Testing Company Name: Donlee Pttmp Company PhoneNo.: 209 537-9396 Testing Company Address: 2825 Railroad Ave Cores, CA. 96307 _ Date of Testing/Servicing: � UN -036 -- I/G www.anitloes.or-g Rev. 01/17/09