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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 equipmenL A separate certification or report must be orepared 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 Informatio �.� Facility Name: ��r��J �'J 7 �5 l Bldg.No.: Site Address: y855 /71=7C1 �� City: CA�el� Zip: Facility Contact Person: 1_7( Contact Phone No.:O Make/Model of Monitoring System: �lrF' o.�- -�FX`Jtr t[_� j J� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the agpropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: Tank lD: ❑,In-Tank Gauging Probe. Model: ❑ In-Tank GaProbe. Model' Annular Space or Vault Sensor. Model: Space or Vault Sensor. ModeL' �r'6�� Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: ZCL43�✓ Fill Sump Sensor(s). Model: ill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 'C t ❑ Electronic Line Leak Detector. Model: ❑ Tank'Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment tv a and model in Section E on Page 2). ❑ Other(s cify equipment ty a and model in Section E on Page 2). Tank ID: - Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: T SY 3 F-C/^Y02 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Madel:7ld?Y'-02 228 ❑ Piping Sump/Trench Sensor(s). Model: ❑ 'l]Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: °�Q��" ❑ Mechanical Line Leak Detector. Model: lectronic Line Leak Detector. Model: - ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Cl Tank Overfill/High-Lcvel Sensor. Model: ❑ Other(s ecify a ui ment ty a and model in Section E on Page 2). ❑ Other(soecify equipment ty a and model in Section E on Page 2). Dispenser ID: J—. Dispenser ID: 7— Dispenser Containment Sensor(s). Model: %e/3Y''Cl C F Dispenser Containment Sensor(s). Model: yr/r/3 'Ze9 Shear Valve(s). 4Shear Valve(s). ❑ Dispenser Containment Float(s)and Chnin(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: S" ispenser ID: `-S Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Mantis)and Chain(s). O Dispense Containment Floats)and Chnin(s). Dispenser ID: '/_/10 Dispenser ID: /I r Dispenser Containment Sensor(s). Model: �f*,.�'SPtI--IDS 1 Dispenser Containment Sensor(s). Model: S T Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Cl Dis enser 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 correct and a Plat Plan showing the layout of monitoring equipment For any aqui ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): JOhn Courant Signature: Certification No.: (5"I 07 ' 03_'K License.No.: 1R44Rn Testing Company Name: Scott ( n of ral i fnrni R Phone No.:(-&j49--) 8951-9744 v 385 Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification