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` F MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of alifornia Authority Cited. Chapter 6.7, Health and Safety Coate; Chapter 16, Divisioi 3, Title-13, California.Code of Regulations This forth must be used to document testing and servicing of monitoring equipanent.A separate certification or report must be prepared for each tnonitorittt'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 W the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: _ f-�'l."T L r t.., MAIC 0 Bldg.No.: Site Address: - ;z'Y-9-o C� 1-dt-t-kF- RZ) City: y t - - Zip: Facility Contact Person: Contact Phone No.:( _) Make/Model of Monitoring System: 9 t L4'40-c0 C—JkC- Date of Testing/Servicing: S. Inventory of Equipment Tested/Certified Check the nate boxei to indlcate s tic ment ins edlserviced: Tank ID: t3 Tank ID: :!t5Z .nk Cra3aging Probe. Model: t� C�-G Tank Gauging Prof. Madel: ^C Annular Space or Vault Sensor_ Model: a.269 11 Y'ft7op �°uiar Space or Vaunt Sensor. Model: _ZSq f 15E 6 �ing Sump/Trench Sensor(s)- Model: A o�591Ococ30ci 0 .ping Sump/Trench Sensor(s). Model "eec ❑ }?ill Sump Sensor(s). Model: Cl Fill Sump Sensors). Model: mechanical Line Leak Detector. Model: I-Ze ri C A Et-Me—chanical Line Leak Detector. Model: e-D a-0c2x'a D Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: 0 Tank Overfill f High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model:. ❑ Other(s . e ui mnt=and model in Section E on Pae 2). ❑ Other(s e i nt=and model in Section E on Pale?). Tank Ills /L! e 13- ✓ t D _ Tank 1D: 2 rn-Tank Gauging Prone. Model: 414C - ❑ In-Tank Gauging Probe. Model: Cd`Annular Space or Vault Sensor. Model: �-2"1 i 4 Vea ❑ Ann ular Space or Vault Sensor. Modei: i-Piping Sump/Trench Sensor(s). Model:R40'-'T'7t2-zOr COCp ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fin Sump Sensor(s). Model: mechanical Line Leah Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electrouic Line Leafs Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model. ❑ Other(s ui mens rype and model in Section E on Pae 2). ❑ Other(s ifv e ui meat M.and model is Section E on Page 2). INspenser ID: 1 `- Dispenser IA: i ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 8-5ficar Valve(s). a-SEeas Valve(s). !"> is nser Containment Float(s)and Chain(s). nser Containment Float(s)and Ctain(s). Dispenser ID: 31 Y Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: shear Valve(s). ❑ Shear Valve(s). .IZRpis nser Containment Floats)and Chain(s). ❑ Disnser Containment Float(s)and Chain(s). M-. S—�. Dispenser ID: Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Valve(s). ❑ Shear Valvc(s). user 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 ideatified in this document was inspeeted/servieed in accordance with the manufacturers' guiidelizms. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the layout or monitoring egai ent. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply); S�rstem set-up ff 1, history port, Technician Name(print): 4 v +-,L, �y/4 bit l�1d - _ Signature: � 7 Certification No.: License.No.: - Testing Company Name: '.)?9S rSlo>J fAAJK L4L5ntv6- Phone No.: o 6 5'yq 3 Site Address: %2 Y.9--n G&4r -t Lt vE 9 D, TWA--V Date of Testing/Servicing:—jJ t f L03 Page I of 3 D3tox Monitoring System Certification r