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Aug 31 09 08:58a Elite IV Contactors 120946 6342 p.3 Mor�aTIJRING SYSTEM CERTIFMATION Fco- !Isz Aulhorft Ole& Ch,7prer 6.7. Ifealth and S421,ejy Code: Chapter 16. Diviriwo 3. ride 13. Caftf,rata Code or Regul4tiOns This form must be used to document -testing and servicing of monitoring equipment. if more than one monitoring system control panel is installed at the facility, a scoarate certification gr report must I& P=241ed for each monitoring systemmust be .coulMl panel by the technician who performs th& work. A copy of this form provided to the tank system ownerlopmtor. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. A. General litformation Facility Name: S.4;C A ddrcss: .- Facility Contact Person: Mair/Model of Monitoring System: —l -L -S �0 Bldg. No.:, City: Lal=_Z 4 - * �? C Contact Phone No.: AFY� :2:�k J-4 V/ Date of TesTing/Scr-icjmg: 4 / 0 01 B. Inventory of Equipment,TestediCertifled Check the mero -ectedfservlced: zdate boxes to indicate ocifle mi taint ens Tank ID: Tank ID In-Twk Gauging Probe. Model: --Tank Gauging Probe. IvIodel:_ AA9C-A ILAS Aurmlar Spstx or Vault Sensor. Model: /-14 Fs XAtmulxr Spacc or Vault Sensor. Model-. Pipitig SutnpTri:nch Scnwr(s). Model: 8 'PkPiping SurnpMench Sensor(s). Model: 0 Fill Sump Seax*s). MOM:E) Fill Sump senwr(s). Model: �Rf Mechanical Line Lcak Detector, Model: &Mcchanical Line Leak Detector. model: U Electronic Line Leak Detector. model- to Electronic Line Leak Detector- Model: • Tank Overfill I fth-Leycl Sensor- Model- 12 Tank Overfill I Hit"evel Sensor. Model: Dispatwer C senzor(s). Modcl- ispender ContataxneAt Sensor(s). c1hesir Model; • Shcar Valve(&). �-Pa valve(s). 0 Conairwacut Flau(s) and Cham(s). Cl Dispeaw Con miarnent,Floats) and Cbzin(s). 0 Oew Lsffci tri =t = and model in Section E on NSc 0 Other (specify equipMj!Lt rand model in Section E on Face 2). Tank ID: 'I I Tank Me In -Tank Gauging Probe. Modcl: "A46 aj Q to -Tank Gauging Probe. Model: &nDUW Space Of Vault SCrisor. Model(4,40 U Annular Space or Vault Sensor. Model: Xpiping-surnprTrcrwh Semux(s)_ , Model: 0 Piping Sump(Trcrich Scusor(s). Modet- .0 Fill Sump Modcl: Cl Fill Sump sensor(s). Model: *icchatimai Linc Leak Detector. Modcl: 0 Mechanical but Leak Detector. Model- • Etcctfouic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model-. • Task Overfill / High -Level Sensor- Model: Q Tank Overfill / High -Level Sensor. Model - X DiSp=Xr COntsiftinerA Strutor(s). Model: —0 5— 11 Dispenser Containment Scasor(s). Model: Q skew valve(`). Cl Sheri VAVC(3). 0 D*www Cbritainincut Flost(s) and Chain(s). 0 Disptzssa Contaimnem Flost(s) and ChaWs). 0 Other (sp=ifv u!Zam = and model in Section E on Page 2). 0 Other (su" nt and tnodd in Section E on Pae 2). C. Ccrfiftstift - I certify that the equipment identified in this document was Inspected/servired in accordance %with the m2nufmict1ii-m" guidelines. Attached to this CeriUlcation is inforniatiou (e.g. watsufacturers' checklists) necessary to verify that tbfs information is correct and a She Plan showing the layout of monitoring equipuient- For any equipment capable of generating such reports, I also arcacbed a copy of the (ckick ia that apply); C3 System set -'up - report - CU) arm history report. Technician Nw= (print):No.. ture- Signa I mr Tcs=g Compa-y NamePhone No.: �W4u WZY"