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(hit HL ��Uvt KION(PORING SYSTEM CERTIFOATION N40 12 2007 Por Use 4v.41l Jurisdictions Within the Slate of California authority Cited: Chapter 6.7, Health and Safety Code; Chapter/6, Division 3, Title 23, Crr/ifornia�Q{(e of Re datip/�EA�(}{ This form must be used to document testing and servicing of monitoring equipment. A separate certification or areperRt`YtW% prepared for each monitoring system 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 oftf-st date. A. General Inf rmation Facility Name: I, .0 riBldg.No.: Site Address: Q 'G. I �h_ 'f� City Zip: Facility Contact Person: n m tM/nM� a Contact Phone No.: (�°L),I A3L Make/Model of Monitoring System: T-1,s "5n Date of Testing/Servicing: eL.I�L(ol-Qy B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID* Tank ID: 13 In-Tank Gaugin�e odel: 131!-Tank Gauging Probe. Model CYC� / ® nular Space or Vault Sensor. Model:7 9'j 342-N 2� t7 Annular Space or Vault Sensor. Model: 7z /-"tet,"�,)9 U'Noing Sump/Trench Sensor(s). Model: 74_ 3 30R' R1 • g Sump/Trench Sensor(s). Model: OrSC Somp Senser(s). Model:� - Fill Sump Sensor(s). Model: 31RO.20 ❑ 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(slecify equipment a and model in Section E on Page 2). ❑ Other(s eci equipment t e and model in Section E on Pae 2). 'ranklD: 99f- Tank ID: ❑ II Tank Gauging Probe. Model: V p ❑ In-Tank Gauging Probe. Model: E9" ranular Space or Vault Sensor. Model: G' - .0 ❑ Annular Space or Vault Sensor. Model: I iiping 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(s eci equipment t e mid model in Section E on Pa/�1a 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: ��/x,� T}-d,n�frm✓/ U✓m7tr+ Dispenser ID: ❑ Dispenser Con[mnment 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). 7Dienser 1D: — P_ h Mp Dispenser ID: spense:,C^ nm�_t Sensoi(s). Model Zi,03' ❑ 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). Diporrser ID: - nsor(s). Dispenser ID: UT Dispenser Containment SeModel: o7•(J(J bra ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tracks or dispensers,copy this form. In`cjlluddee infor/mjs�'on for every tank and dispenser at the facility. C. Certification 1 cert[y that tile c en identi tc m is 2"21, en w s inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manu acturers' 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,1 have also attached it copy of the report;(cGeck n//rhnt npp/r): ❑Sys m sebu arm history report Technician Name(print):T� !J. ,�/Gt7yY�TC Signature:' I�, ✓! t�aae.-m+"� Certification No.: y-- License.No.: rQ"(,Y�_��'TJI ,/L/ Testing Company Name: F"V-'tD a {�-P S✓ Phone No.:(�)7'7WJ Dl/ -:z Site AddrDate of Testing/Servicing: a2. 4L E J Page 1 of 03/01 Monitoring System Certification D. Results of Testing/Servicing