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MONITORING SYSTEM CERTIFICATION 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: F)Mo 44T52 Site Address: ILe t. AarainA City: Bldg. No.: Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: ��1(d1dlJ( Q� �,5�3 Date of Testing/Servicing: , /?_7Z B. Inventory of Equipment Tested/Certified Check the n r rinte bevel i0 indieflte soecirlc enuiomen t insoected/serviced: "If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the tecility. 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 . correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report TIO Pic+^*fr' Technician Name (print): 'Thy F'nmf-an;; Signature: Certification No.: Q d�1"in'�'� a License. No.: I S44en - - Co • r�.f California Phone No.:(sin ) Rg5-9-un Y -ig� Site Address: J�e7 C-` ��tf�C Date of Testing/Servicing:I�� Tank ID: Tank ID: ❑t -Tank Gauging Probe. Anular Model: O In -Tank Gauging P be. Model: i5' Annular Space or Vault Sensor. Model: Space or Vault Sensor. Model: X Piping Sump / Trench Scnsor(s). Model: APiping Sump / Trench Sensor(s). ModeL1441bI J `20b ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Linc Leak Detector. Model:.C.F.T, A& Elcetronic Line Leak Detector. Model: •a• CP'T ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Scnsor. Model: Cl Other (specify equipment tv a and model in Section E on Page 2). ❑ Other (specify equipment ty a and model in Section E on Pace 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank GaugQ Probe. Model: Annular Space or Vault Sensor. Mode ly3' 4r ❑ Annular Space or Vault Sensor. Model: ptPiping Sump / Trench Sensor(s). Model _ ❑ Piping Sump /Trench Sensor(s). Modcl: ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: AS Electronic Line Leak Detector. Model: IK.1, C�"i-• ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty a and model in Section E on Pace 2). ❑ Other (specify equipment type and model in Section E on Pace 2). Dispenser ID: l"Z Dispenser ID: X Dispenser Containment Sensor(s). Model:�e *9 Dispenser Containment Sensor(s). Model: Q °J%_Z1V0 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Flout(s) and Chain(s). Dispenser ID: t, Dispenser ID: -1' t) Dispenser Containment Sensor(s). Model: Dgym—boo Al Dispenser Containment Sensor(s). Model:'1g44Sft :2201P ❑ Shear Valve(s). ❑ Shear Valve(s). O Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: C�— l0 Dispenser ID: Dispenser Containment Sensor(s). Model .Qu*,A=fa t) PU Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). ODis enser Containment Floats) and Chain(s). O 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 tecility. 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 . correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report TIO Pic+^*fr' Technician Name (print): 'Thy F'nmf-an;; Signature: Certification No.: Q d�1"in'�'� a License. No.: I S44en - - Co • r�.f California Phone No.:(sin ) Rg5-9-un Y -ig� Site Address: J�e7 C-` ��tf�C Date of Testing/Servicing:I��