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MONITORING SYSTEM CERTIFICATION Ar Use Sy All Jurisdictions Within the Stare of California AuthoHry Cited.,Chapter 6.7, health and Safety Code;Chapter 16, Division 3, Tide 23, California Code of Regulations> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report mus[be orenared for each monitoring system control caneby the technician who performs the work. A copy of this form most 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. A. General Inf9pnation Facility Name: Xff4'S' L rQKv / Bldg. No.: Site Address: /yoS City: PS''ef 4(oxJ zip: LC Facility Contact Personel-(4 C kc) Contact Phone No.:(2 O9 1 *I L— l tf Make/Model of Monitoring System//)g c o £'MC Daze of Testing/Servicing: 31 7/C3 B. Inventory of Equipment Tested/Certified Check the approp,nate loxes to indicate speeffle aqui went 1 serviced: Tank ID: is n L Tpk ID: a-fn_Tank Gauging Probe. Model U'__Tank Gauging Prole. !lode! Cr-Ammlar spam or Vault Sensor. Model: 1fLJg� tlaspace orVan([ Model: i�iping Sump/Tench Sensor(s). Model: 022f 110X,.is g Sump/Trench Seusor(s). Model- i O Z-1 1:')11 Sump Semor(s). MotkL ❑till Sump sensot(s). Model lechaaical line Leak Detector. Model• �/F- 8-iGlechatticaI Line Leak Detector- ModeL• U Electronic Line Leak Detector, Model: Cl Electronic Line Leak Detector. Model: ❑ Tack Overfill fHigh-Level Sensor. Model: 0 Tank Overfill/Higb-Level Sensor. Model: U Other( i went -and model in Section E on P 2). 0 Other(specify equipment and model in.Secrion E on Pa 2). KMT�g Tank ID:Model ❑ In-Tank Gauging Probe. Model rModel- ` d BC 0 Annular Space or Vauk Sensor. Modelump/Trench 3ensor(s). Model• P/3Q25 .2.C)UC0.10 0 Piping Sump/Trench Seasor(s). Model- , ❑gill Sump Sensoris). Model• ❑ Fill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Modek (( . .. ❑ Mechanical Line Leak Detector. Model' 0 Elecaanic Line Leak Detector. Model: O Elecurme Line Leak Detector Model: 0 Tank Overfill/High-Level Sensor. Model: Cl Tank Overtiil/High-Level Sensor. Model- 1 ❑ Other( men[M and model in Section E on Page 2). 0 Other( eqtdpment pM and model in Section E on Page 2). Dispenser IDt / .A-Z. D peu,9e.gy 7 j-: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model hear.Valve(s). tYShear Valve(s). Ul*ffmpcmcr Containment Float(s)and Chain(s). 5-15is Containment Float(s)and Chaia(s). Dispenser ID: Dispense.ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s), 0 Shear Valve(s). O Dispenser Containment Floats)and Chain(s). 0 Disvenser Containment Ficags)and ChainW. Dispenser ID: Dispenser ID: 0 Dispenser Containment Screor(s), Model: 0 Dispenser Containment Sensor(s). Model: O Sbenr Valve(s). 0 Shear Valve(s). 033ispenscr Containment Float(s)and Chain(s). 0 Dispenser Containment Flaat(s)and Chaiu(s). *If the facility courainc mora tanks or dispensers,copy this form. Include infotmadon for every rank and dispenser at the facility. C. Certification-I certify that the equipment identified is this document was inspeeted/ser-vieed in aceoedanee with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the repcA(Fhec,{(,pl(thatapply): L7 System set-up ❑alarm ort Technician Name(print): � S / =cnr�/'I i Signature: Certification No.: / Z License.No.: i Testing Company Name: i ti r4> '/. Phone No,:t 15 f'l7 LEI,,)•-?Yy i Site Address: �.� ': /",x, 6;rt i - JV S( Date of Tesung/Serviciug: Page 1 of omi ' Monitoring System Certification