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ray-4MO UV:ooam rrum-Gaoler^t HC tilIR301lo1! 1_019 r UUc/VUa r-410 For Use Ey x111 Juriydiclions Within the.$tate of(7fj.1zfornita .-Iuthority Cited: Chapter 6.' Wealth and Sgfc'ty Cude; Chapter 16, Division 3. rillE 23, Callfarnfa COLIE of Regiiiaticn3 -Phis fort must be used to docurneti testing and servicing of monitoring equipment. A separ,t:~ certification„ur report must t rrc ared far each monitorirt system control anel by the technician who performs the work. A copy of this formust be providcv , the tank System owner,'operator. The owner operator must submit a copy of this forret to the local agency regulating UST 4r:,r,n within 30 days of test date. A. General Facility Name: �52 r _ ._ _ Bldg. No.: Site Address lf - yu.Y� '— _ City S)�cCcT29 _ _ Zip: 2-c;-> Facility Contact Person: Contact Phone No.: Makeir"Model of Monitoring System: :1 ' n � Hate of Testing/Servicing: ! � B. Inventory of Equipment Tested/Certil aed Check the appropriate boxes to indicate specific equipment inspeocdiserriced: [OFill ID: C3GI Tank ID: -Wank triaging Probe. hfodel: Qin-'fa augin Probe. Model: nnular Space or Vault.Sensor. Model: ❑ Annular Sppe e`dr-v% cnsor. Modal: ping Sump I Trench Sensor(s). Ntpdel: ❑ piping Sump/Trench Senso s . oriel; Sump Sensor(s). Modei: Cl Fill Sump Sensor(s). Mode: _ echanical Linc Lcak Detector, Madel: Q Mechanical Line Lcak Detector. Model: `-w ectranie Lina Leek Detect". Mxi Gl: U Electronic Lime Leak Detector, Model: �.. ❑ Tante Overfill/High-Level Sensor. Model-. Q Tank Overfill/Nigh-Level Scnsor. Model: Q tither(specify equipment type and motel in Section Eon Page 2). Q other(s]5"Ifq equipment type and model in Section E on Page 2). Tank ID• Tank M- O In-Tank Gauging Prole. i44e1: n,1 a�tak Gauging Probe. Modei: 0 Annular Space or Vault Sensor. Model: O Annulai Spaces,or Vault Sensor. Modal: ® Piping Sump/Trench Sensor(s). Mendel: Cl Piping Sump I Trim!-Scnsor(sModel. ❑ Fill Sump Sensor(s). Mt dcl: U Fill Stamp Scnsogs). Modcl: Cl Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector. 0 Electronic Lane Leak.Detector. Model: ® Eicctronk Lute Leak Detector. Model-. �. ❑ Tank Overfill/High-Level Sensor. Model: D Tank Overfill 1High-Level Sensor. Model: Q Other(specify equipment type and rnod'pl in Section E on Page 2). Q Other � (specify equipment type and model in Section E on Page 2). Dispenser ID: oxer ID: 0-Disi2criser Containment Sensor(s). Mo del: Gl Dis s`cr" aadsmSer�snr(sj. Model: ❑ Sheaa'Valy s.. - Cl She"Valvc(s). ❑ Dispenser Containment Float(s)and C i`n )r- Q Dispenser Contain ent Floats)and Chaiti(s . C1ss{anser II3; Itis nat,> f)<TT} Q L)aspense 7GbntairtiLtent Sensor(s). Model: ❑ Dispcnsu o tt Seatsor(s). Model: ❑ Shear Valvc(s). 0 Shear'Valvc(s). :at(,)�.ridCl Dispcnser Containment Chain (•s)_, 0 Dispenser Containment Float(s)and Chairs Dispenser ID: D, p ❑ s eraser Ccntainmcnt Sensvr(s), Model; Cl DispenserE :3t Sen_ sor(s), Nlodcl: ❑ Shear Valvas . CJ Shear Valve(s). ~- CTDispcnscr Containment Float(s)nn 'Ct,a4h(s)__ ❑ Dispenser Ccntainmcnt F1oat(s)and Cha rtfs}_ 'If the facility contains more tanks or dispe:aser5,impy this ibtm. Include information for every tank and dispenser at the facility. ; C. t-ertilication - 1 certify that 'the equipment identified in this document was inspectediserviced in accordance with the manufacturers' kuidelines. Aitachcd to this Certification is information (e.g. manufacturers' checklists) necessary to terify that this information is correct and a Plot pli r I n Shuatiing the layout of monitoring equipment. Ff)r ;any equipment capable of genernting ,uch reports, I hale:ttsn;attached a copy t f rite report; rc/rrR'k.alt fleet!=tpptl'J: .'irstem set-tap 7 Alarm himory report I 1:•,hrl:ciml ,i:atAi •t!:ar): ._t• '_.G „-� _ _. _ ... ... `ignnture: 1 .,.it>cstirn A �-�. _ ® I L,,_cn;e.No 1': Iia' t •It:) .ti :t:. � i f�L/� � tAV � .. ... t .atC 't l•C'it{l i_' �{:r�'!.'Itll_ I Yn p 1 of 3 u t III 1