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MONITRNG SYSTEM CERTIFIATION 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. A separate certification or report must be 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 of test date. A. General Information Facility Name: Bldg.No.: Site Address:— /�dw. /tel City' Zip. Facility Contact Person: �� Contact Phone No.:( &2 ) Make/Model of Monitoring System: n5-3Date of Testing/Servicing: LL1�10 D. luv2utoiy vi n,yurNaucaat ac5c2w�u.i..eu FTankID: xh a to riate bores to indicate s eci Gee ui ment ins ected/serviced: Tank ID: k Gauging Probe. Model: O In-Tank Gauging Probe. Model:ar Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Sump/Trench Sensor(s). Model: �IeJa3,!kj& 0M 0 Piping Sump/Trench Sensor(s). Model: mp Sensor(s). Model: 0 Fill Sump Sensor(s)- Model: anical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: onic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(s ecif a ui ment t)Te and model in Section E on Pae 2). 0 Other(specia equipment[ and model in Section E on Paye 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model O Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(seecia a ui ment t)ye and model in S...e��ec...t```ion E on Pa a 2). 0 Other(s ecif a ui merit t e and model in Section E on Paoe 2). Dispenser ID:01 $tr A65c- T/u A Dispenser ID; *L3 G 0 Dispenser Containment Sensor(s). Model: AO W=w4m_ 11 Dispenser Containment Sensor(s). Model CO a Shear Valve(s). tl Shear Valve(s). 0 DisjjFnser Containment Float(s)and Chain(s). 0 Dis enser Containment Float(s)and Chain(s). Dispenser In - Dispenser ID: • Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: 10 Shear Valve(s). 41 Shear Valve(s)- 0 Dispenser Containment Float s)and Chain(s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID: Z. Dispenser ID: 0 Dispenser Containment Sensor(s). Model:FAVCMT& d Dispenser Containment Sensor(s). Model: Afod &*Shear Valve(s). R Shear Valve(s). 0Dispenser Containment Float(s)and Chain(s). I 0 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 noring equipment. For any equipment capable of generating such reports,1 have also correct and a Plat Plan showing rhe layout of mer attached a copy of the rep rt•(check all that aPP 1): 41 System set-up Q Alarm history report { u f Technician Name(print): i- C dusk - Signature: /6 Certification No.: 1,20 License.No.: n 7. Testing Company Name: ��/ jraa ��GI ,- P"" PhoneNo.:( Site Address: a_5_tul�Gt�e tJf S�Ly�67lJN Com' q t- Date of Testing/Servicing: /i «�u� ---- Page I of 3 03/01 Monitoring System Certification