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SHIELDS, HARPER & CO., LIC. # 803011 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Siate'of Ca(farnio Authority Cited;Chapter 6J,Health and Safety Code;Chapter 16, Division 3, rifle?9, California Code of Regulations This form must be used to document testing mid servicing of monitoring equipment.A separate certification or mt niu ft, prep 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 ownenoperator. The owner/operator must submit a copy of this forts[to the local agency regulating UST systems within 30 days of test date. A. General Information 1 ' � Facility Name: M 4LCI -._ Bldg.No.: Site Address: City: Zip: Gy / Facility Contact Person: Contact Phone No.:UQq_3= i& Make/Model of Monitoring System• �(.�1 7'�✓- Date of Testing/ServicinW- B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indleaet a earl.l' ai mcat Inn Ytcj/.v"jccd: Tank lD: _ Tank ID: tem lal^Cn=fapk Gauging Pro i . Model: U_ rr `I r� +t-l'attk Gauging Probe. Model: u ar Space or Vault Sensor. Model: ,9 " pNAnnular Space or Vault Sensor. MMCI:,�'(� iping Sump I Trench Scnsor(s). Model: Nping Sump/Trench Sensor(s). Model: _ Wr Fill Sump Somot(s)_ Model:_ ill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: d Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl Electronic Line Leak l3d"tor. Model: p 'tank Overfill/High-Love)Sensor. Model: O Tank Overfill/High-Level Sensor. Model: O Other(s2"1!k e ui mens an model in Section E on PSge 2). d Other KspoOly,equipment type and model in Section E,on P e 2): TanIXJD: Tank M: Wra-Tank Gauging Probe. Modcl: 13 In-Tank Gauging Probe. Model: arrlu mlar Space or Vault Sensor. Model:, ❑ Annular Space or Vault Sensor, Model: piping Sump/Trench Sensor(s). Model: C3Piping Sump/Trench Sensor(s). Model: ak P"Fill Sump Sensor(s). Madel: Q Fill Sump Sensor(s). model: O Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: p Electronic Line teak Detector. Model: p Tank Overfill/High-Levol Sensor. Modal: Q "fgnk Overfill/High-Lcvcl Sensor. Model•. ❑ Other specify ui meht pr and model in Sec_tion,E OwPAge 2). -(3 Other(specify a ui ant type and model in Saccion E on Pa 8:). Dispenser ID: Dispenser ID: ®'D-spenser Containment Sensor(s). Model: �W✓p in ispenser•Contuinrnent Sonsor(s). Model: QI'Shoar Vxlvc(s). P7 Shear Valve(s). ` ❑ Dispenser Coruai mt Flout(s)and Chains), ❑ Dispenser Containment Floats)and Chain(s). Dispensur[D: Dispenser ID: p Dispenses containment Sensor(s). Model: pensar Containment SensoKs). Modcl: ❑ Shear Valve(s). Shear Velvc(s). ❑ Dispenser Conrai ent Float(s)and Chains). p Dis nser Cc tainme t Float and Ch 'n(6). Dispenser ID: Dispenser ID: cr Containment Scnsor(s). Model: 74(� �ispensar Com nmant Saneor(s. odeL•'�/ rhear Valve(s), 3-Shcar Valve(s). CIDIspinser Commitment Flouts and Chain(s). l7 Dispenser Containment Float(s)and Chain(s). elf the facility contains more tanks or dispensers,copy this form. Include information for every tank and disperser at the facility. C. Certification-I certify that the equipment identified in this document was inspectodlserviced in accordance with the manufacturers' guidelines. Attached to this Certification u 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 capahle of generating such reports,I have also attached a copy of the re ort; ^p(l rJ,ut appfy): E'System set-up lKlarm his ory r por Technician Name(print): s,,,�Q4/G��n Signanue. JJ Certification No.: License.No.: l Testing Company Name: Phone No.: Sic— SiteAddress: Date ofTesting/Servicing: l2l/1 /U Puge 1 of u31o1 - Monitoring System Certification