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MOTORING SYSTEM CER1 ICATION For Use By All Jurisdictions Within the State of California Authority Cited:-Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. i 4 4 0 PA.,Q" "'a'104 *hLA seQarate certification or report must be prepared for each monitoring system control panel by the technician rforms the work. A copy of this form must be provided to the tank system owner/operator. The owner/ope r i f to a local agency regulating UST systems within 30 days of test date. A. General Information DEC 19 2017 Facility Name: Rope G,,-. A- } � - MEN-HL��' u� Site Address: 'tc{ 1r1. �xi;t�l-l►i�v� e,A• City: _° del pN 1p: Facility Contact Person: C M e5h, Contact P ol95oA Make/Model of Monitoring System: \l ge..L-er ec.-.+ -1% �p Date of Testing/Servicing: Ga B. Inventory of Equipment Tested/Certified Check the agpropriate boxes to indicates ecific a ui q ent inspected/serviced:: Tank ID: <;--1 Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: '7 ❑Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: VMI%-D?u� Mechanical Line Leak Detector. Model: V Hi k D 2tMo ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model. ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: -Z Dispenser ID: ADispenser Containment Sensor(s). Model: —2UB Dispenser Containment Sensor(s). Model:--201f ❑Shear Valve(s). Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-4. Dispenser ID: "L—�► Dispenser Containment Sensor(s). Model: -- 1L Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. 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 Site-Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): lral�'jf System set-up Alarm history repot l Technician Name(print): Tony Fontana Signature: Certification No.: V.R.A23686 ICC 1064273-UT License.No.: A'--66288 Testing Company Name: U.S.T. Compliance Testing Inc. Phone No.: (209) 595-4489 Testing Company Address: P.O. Box 580 Ceres, CA 95307 Date of Testing/Servicing: UN-036-1/6 www.unidoes.org Rev.01/17/08