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MONITORING SYSTEM CERTIFICATION AUG Auth-ity' Cited: Chu ter h. l °t' Use BI ,4/l.lrrr'isdirtir»ts I4'rrhin thc� ,Stnt� orC'a1,for niu P Health unt f Sgfeli' Cade: chapter !l, • Division 3, Title 23, C'ultJ��rnin Code uf'fi4�ulotiv� , M®' This ft)Pm must 11C Fl., I to dpenl"elll _10itiv acid scicifonirineqin.A rate r c ort f st Vc aretf tr ' thosugte technician %% ho perfi)rms the work. A copy of this form must he provided to the tank system owner/operator. -fhe o%%ncr.•operatnr must suhmit a cope 611'thi% i01"ll to the local agenc) regulating t)ST systems within 30 days oftest date. A. General Information Facility Name:_ , `C V t Bldg. No.: Site Address: .� Zip: Facility Contact Person:�� (� ) �!� e �7 Make/Model of Monitorin. I g System: Contact Phone No.: �- 3 b Date of Testing/Servicing: B. Inventory of Equipment 'rested/Certified the appt'apriale hexes to indien Tank ID: Model: A I'ank Gauging I'robc• Model: ILAO 4imular Space or Vault Sensor. tvhWJ& 1�14PO119 Sump 11'rench Sensor(s). Model: © Fill Sump Scltsar(s). Model: ilodcl: Mechanical Linc leak Detector. Model: ® Electronic Linc Let)k Detector. Modcl:- 5'rank Ovcrlill t I ligh-Levet Sensor. itodcl: ❑ Other (spccifp equipment tcpc and model in Section li on I it c 2). Tank ID: Moder 2 lo-4rank Gauging wohc. Model. Annular Spacc.pr Vattit tensor. Chain(s). ping unip'! 1'rcnch 5ensar(sd. Model: -Z � ❑ Fill Siimp Sensar(s). Model , Mechanical Linc Lcak Detectur. [Model: Q Electronic tine Leak 1)ctcclor. Modcl. i,•'I'ank Overfill i I ligh-Level Sensor. Model: ❑ Other (spL61y equipment type and model in Section li I Pt ;c 2). Dispenser ID: ❑ Dispenser Contain tent Scnsoris). Mode L• fear Valvets). pciiwr C•on(ainment hloat(s) and Chain(s). Dispenser ID: ❑ DispenserC(mtainmcnl Sensorts), Model; Q Shear Valve(s). ❑ DispenserComainnicttt Floal(s)and Chain(o. Dispenser ID: © llispcnscr i'ontainmcnt Scnsor(s}• Model: 0 Shcar Vulve(s). IJ t)ispcnscr ('antuinmellt Floatts) and Chain(s). Tank ID: 44lt=Tank Gauging Probe. Model: A QA�lnntdar Space or Vault Sensor. Model: ILAO Piping Sump /Trench Sensor(s). Model: Zge, Pill Sump Sensor(s), Model: Mechanical l.inc teak Detector. Model: lleciroinic Lille Leak Detector. Model: ` •lank ONerlill t High -Level Sensor. Model. ❑ Other (spcory cquipment type and ma del inSection ti o�'ag4 •2), El In -Tank Gauging probe. Model: -- ❑ Annular Space or Vault Sct)sor• Model: ❑ Pipiltg Suntp 1.1'rench Sensor(s). Model; ® Fill Sump Setsor(s). Model: ® Mechanical Line Leak Detector. Model: ❑ Iilectronic Line Leak Detector. Model: ❑ 'Tank Overfill 1 I ligh-(.evel Sensor. Model: ❑ Other (speci rt' equipment type mid model in Section E on Page 2). Dispenser ID: _ 3 Q © Uislxnser Containment Scnsarts). Moder hear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Dispenser Crnttainment Floats) and Chain(s) Dispenser ID: © Dispenser Containment Sensor(s). Model: 0 Shear Vafve(s). ❑ Dispenser Containment Float(s) and C'hain(s) *If the facility contains more tanks or dispensers, cup} this I'urm. Include itillormation dor every tank and dispenser at C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I hal"e: also attached a copy of the report; (check all that app(y): ❑ System set -pp ❑ Alarm history report Technician Na(ne (print): GABRIEL VENEGAS Signature: Certification No.: 840893 _ _ License. No.: Testing Company Name: L.0 SERVICES Phone No,: (559) 444-1730 TestingCompany Address: 3887 N VALENTINE FRESNO CA 93722 Date of Test ing!Servicing: �q- Page 1 of 3 Rev (2108)