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��r�4 �Aj� - MONITONG SYSTEM CERTIFI�TION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safer}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. Fa General Information it _ 'J� Q�fiZG Bldg.No.: r Facility Name: � Site Address: 4 ezz �� City'—+ .44r t/1 Ztp. Facility Contact Person:�\��h� Contact Phone No.:( Make/Model of Monitoring System: Date of Testing/Servicing: 1L_1Lt_1� D. 1LLVCLL Tory of 'quipLLrCLLI ested/Certifaeu Check the a to nate boxes to indicate s ecific equipment ins ected/serviced:Tank Tank ID: _Cl In-Tank Gauging Probe. D In-Tank Gauging Probe. ❑ Annular Space or Vault Sensor. N��_. D Annular Space or Vault Sensor. 10 Piping Sump/Trench Sensor(s). D Piping Sump/Trench Sensor(s). _ ❑ Fill Sump Sensor(s). L ` ❑ Fill Sump Sensor(s). D Mechanical Line Leak Detector. s\l D Mechanical Line Leak Detector. D Electronic Line Leak Detector. D Electronic Line Leak Detector. D Tank Overfill/High-Level Sensor. I Cl Tank Overfill/High-Level Sensor. D Other(s2ecify Equipment tyee and model in Section E on Pa a 2). D Other(specia equipment and model in Section E on Page 2). Tank ID: Tank ID: D In-Tank Gauging Probe. —____. D In-Tank Gauging Probe. D Annular Space or Vault Sensor. __ __ D Annular Space or Vault Sensor. ❑ Piping Sump/Trench Sensor(s). -__ D Piping Sump/Trench Sensor(s). D Fill Sump Sensor(s). ___ D Fill Sump Sensor(s). L2) D Mechan ical Line Leak Detector. D Mechanical Line Leak Detector. D Electronic Line Leak Detector. _. D Electronic Line Leak Detector.D Tank Overfill/High-Level Sensor. O Tank Overfill/High-Level Sensor.D Other(s ecif a ui ment t e and model in Sectio E on Pa a 2). D Other(s ecif a ui ment t e and model in Section E on Page Dispenser ID:77- G Dispenser ID: -- Dispenser Containment Sensor(s).�r D Dispenser Contamment Sensor(s). T _ D Shear Valve(s). �J(Mi D Shear Valve(s). Cl Dispenser Containment Floats)and Chain(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). D Dispenser Containment Sensor(s)-0 Shear Valve(s). _ D Dis enser Containment Float(sLand Chain s). D Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). D Dispenser Containment Sensor(s). D Shear Valve(s). - D Shear ser Containment DDis nser Containment Float(s)and Chain(s). ❑ Dis 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 certifv 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 Plot Plan showing the layout of monitoring equipment. For any'equipmeert capable of generating such reports,1 have also attached a copy of the repgrt;�check all that apr�I *'System set-up l m history report Technician Name(print): 1 �s ws £/�fl C Signature: Certification No.: 12P3 / License.No.: [",�,� Testing Company Name: Phone WWI— Site .,—'ice— � Address: r'—.344 zl �'ar ZSI Date of Testing/Servicing: Page 1 of 3 03101 Monitoring System Certification