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may-LU-ut: UV;40am rfum-uaitler-10 1flu T4190011011 1-010 r UUc/UU; r-LIo I Fur Use By�I11 Jurischctions Within rhe State c)f ikrnla !uthoriry Cited: Chapter�.7, J1c erlth and S�afery Cude; Chapter 16, Division 3. Title 23, Cahfarnia Ccciv of Regulations =pared for each monitoring system icontrol anel by the technician who performs the work, A copy of this formamu rbepn must t Phis form must be used to docume�tt testing find scrvicin of monitoring equipment- A Separate certificario r o t i2=-- p7 must be provided the tank system owneroperator. Phi owntyr.operator must submit a copy of this form to the local agency regulatirig UST ;v.sterT ithin 30 days of test date. � 0 A. General Information '7 Facility Name: , 12fC� Bldg. No.: Site Address, 111�L ic,/' y ,t.+u, j— r— City = e_K_1< 2A1 — zip: Ys 2,v a Facility Contact Person: Contact Phone No.: Make/Mcldel of Monitoring System: �'1 -~ � Date of Testin Servicin Inventory of Equipment'Nested/Certified � � B. Invero � Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 9 / OCT 'Tank ID: Tan' In-Tank Gauging Probe. ilgtdol: U in-'Pa�attging Probe. Model., Q Annular Space or Vault.Sensor. Miadel. ❑ Annular Spai a cnsor. Model: ❑ Piping Sump/Trcach Sonsor(s), Ivi'pdek ❑ Piping Sump/Trench Senso s C1 Fill Sump Sensor(s). Madel: D Fill Sump Scnsor(s), Mode: _ echanical Lina Lcak Detector, Madel: Ct Mechanical Line Leak Detector, Model: Q Electronic Line Leak.Detector'. M 401: 4 Electronic Line Leak Detector. Madel ❑ 'yank Ovcrftil/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model- C3 other(specify equipmc:m type and morel in Section E on Pagc 2). Q Other(specify equipment type and model in Section E on Page 2). Tank M.- Tank ID- 0 In-Tank Gauging Probe. iZdel: b4n,Tank Gauging Probe. ModeL C3 Annular Space or Vault Sensor. Wdel: O Annular Sparc or Vault Scasor. Model: ® Piping Sump/french Sensor(s). Mpdch 0 Piping Sump I Trent t-Sc,sor(s). Modcl; ® Fill Sump Sensor(s). MgdcE: ❑ Fill Stsdrp Sensor(s). Model. Cl Mechanical Linc Leak Detector. M01 del: O Mechatricai Line Leak Detector, Q Electronic.Lane Leak Detector. Model: D Electronic Line Lcak Detector. Model: D Tank overfill I High-Level Sensor. Mcldel: D Tank Overfill 1 High-Level Sensor, Model:_ Q Other(specify equipment type and model in Section E on Page 2). Q Odw(specify equipment type and model in Section E an Page 2j. Dispenser lJl+: ! user ID: Gfi-Iis mscr Containment Sensor(s). Mddel: C1 Dispenserrrta+nmr [Sensor(s), Model: ® Shear Valy s. 1 ® Shear Valvc(s) ❑ Dispedw Containment Floats)and i?{�)r- 0 Dispenser Containment �1`olt(s)and Chain(s . Dispenser i Dis ;C:d-�j : Q Dispcnsc-r-Cr s' ctgrLt nt Ssnsor(s). Mojdcl: ® Dispcnrot Sensor(s). Model: ❑ Shear Vatvc(s). �� `~---. CI Shear _'13 Dispenser Contain-ant Floats)and Cha, (•S)_, 01 Dispenser Conment Float(s)and Chain Dispenser ID: Disp t}: ❑ s cn5er Containment Sensor(s). h3oJci: Cl Dispenser c:nmrimmcnt Scnsor(s). :Model: ❑ Shear Valves "- -__.., 1 0 Shear Valve(s). 1~ 1 00ispenscr Containment Flolt(s)a i'(s)__. ® Dispenser Containment Floats)and Cha7rt(s).,__ If the facility contains more tanks or dispcnser5,copy this form. Initudc information for emery tank and disprnse r at the facility. C. Certification - I certify that jthe equipment identified in this document was inspected/serviced in accordance with the manufacturers' kuidelines. •lttachel to this Certlficnrion is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plon shtatving the lavnut of monitoring equipment. For any equipment capable of generating Such reports, I have:tlsn attached a copy u the report: (cheek.alt that appJ): 3'sy"gtem set-up ZI Alarm history report { •:;'ittil'.ttil'n �. 4�?q7-® i..t_Cn-;e. No i:' :;Ilk' t .tYi..ti � ra]" V�� }'1U•tfil *!!in 1v rr— i JUN -008 E N !ii�l Li t' r5 rl( l`'i149�i`11 d R Pi i pp t11 E5