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MONITORING SYSTEM CERTIFICATION Authority Cited Chapter 6.7,Health sandd Safety Code By All letthChapter6,ons Within t Divihe sion n 3 California 231 California Cod e of Regulations This form must be used to document testing and servicing of monitoring equipment. -if Enefe thes oil A separate certification or report must be Wrens*P for each moIlitnrinv stern control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. ' �ldt/InQNrtil!'IVTgT. A. General Information Facility Name: Site Address: �i ' Bldg.No.: Facility Contact Person: City: _U ; Zip: ��`-' St Contact Phone No.: ( Z Make/Model of Monitoring System: Date of Testing/Servicing: i 2� t l B. Inventory of Equipment Tested/Cer ified Check the g ro riate boxes to indiestesPedlic cQuipmentluspected/serviceda: Tank P: C]in-Tank Chi Tank ID: q ging Probe. Model: ❑In-Tank Gnu Annular Space or Vault Sensor. Model: »g Probe. Model: Piping Sump/Trench Sensor(s). Annular Space or Vault Sensor. Model: r() Model: f Piping Sump/Trench Sensor(s). Model ❑Fill Sump Sensor(s). Model: >Uaphanical Line Leak Detector. Model: ❑Fill Sump Sawr(s). Model: M l �I>'�f�rti c rT,nk Mechanical Line Leak Detetor.glectronic Line Leak Detector. Model: Moder) Tank Overfill/High-Level Sensor. Model: Electronic Line Leak Detector. Mode: Other(specify equipment type and model in Section E on Page 2). Tank Overfill/High-Level Sensor. Model: Other(specifyequipment type and model in Section E on Page 2). ID: ❑In-Tank Gauging Probe, Model: Tank ID: ❑Annular Space or Vault Sensor. Model: ❑Tn-Tank Gauging Probe. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Annular Space or Vault Sensor. Model: ❑Fill Sump Sensor($). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Fill Sump Sensor(s). Model: ❑Electronic Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑Tank overfill/high-Lead Sensor. Model: ❑Electronic Line Leak Detector. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Tank overfill/I-ligb-Level Sensor. Model: Dispenser ID; C)thFD (sifi«IviPment type and model in Section E on Page 2). Z ❑Dispenser Containment Sensor(s). Modol er ID: ❑Shear Valve(s). nser Containment Sensor(s). Model: -- ❑Dispenser Containment Float(s)and Chain($). Valve(s). Dispenser ID: 5 46(� nser ContainmentFloat(s)and Chain(s). Dispenser Containment SModel: er ID: ..Shear Valve(s). nser Containment Senso s.❑Dispenser Containment Fl Valv s. �) Model: oats)and Chain(s). e()Dispenser ID: ser ContainmentFloat(s)and Chain(s). El Dispenser Cr ID: ❑Shear Valve(s). ❑Dispenser Containment Float(s) Dispenser Containment Model: at()and Chain(s). If the facility contains more tatiks or di ❑Dispenser Containment Floats)and Chain(s). fie° •SPY this form, Include info C` Certification -I tmation for every tank and dispenser at the facility, certify that the equipment identified in this docun' nt was ins guidelines. Attached to this Certification is information (e.9- correct and a Site-pl_t plan showing the layout f rmaiiorin � �rvtc�1p accordance with the manufacturers' manufacturers' checklists) necessary to vers $�0 attached a COPY of the report; g iPment For any eggi meat capable of generating such reportsfy that this aI have P rt;(check aU that apply): Technician Name(print). set-up �•�larm history re (print}: Ton Fontana port Certification No.: V.R.A23686 lCC 5288227-UT Signature. `' Testing Company Name: V.S.T. C License. No.• Mance TeMtln Inc. -- A"846288 Testing Company Address: P.p, gpx 580 Ceres CA I 85307 Phone No.:(209) 595-4489 036—1/6 Date of Tessin g/Servicing: