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o f M019TORING SYSTEM CER ICATION For Use By All Jurisdictions Within the State of Calilbmia Authority Cited-Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code ofRegulations This form must be used to document,testing and servicing of monitoring equipment.A separate certification or re rt must be pLepamd for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the taak system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within- days of test date. A. Generallnformatio Facility Name: C lji j e STc", � �G S ti'% BIdg.No.. Site Address: ?�o t{ ? lip N�___ o City: 4 �� Zip: SU Facility Contact Person: Contact Phone No.: { a O`� ) �1cj's- �� Make/Model of Monitoring System: � j �L — Dates f Testing/Servicing: 6/7 /0(1 B. Inventory of Equipment Tested/Certified ? S�S�y� '8990 Q0/� Check the ro nate boxes to indicatespecific a ui mcnt inspected/serviced: Tank ID: nc'm t X71 Tank ID: C)O g In-Tank Gauging Probe. Model: -` J9 In-Tank Gauging Probe. Model: ,! Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model:V - 0 l�f Piping Sump/Trench Sensor(s). Model:LA— S! C I� Y , Piping Sump/Trench Sensor(s). Model: f fj ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-level Sensor. Model: ❑ Others i ui ment type and model in Section E on Pae 2).. ❑ Others ci ui ment and model in Section E on Pa e 2). Tank ID: v Lj Tan A In-Tank Gauging Probe. Model• ❑ In-Tank in Probe. Model 0 Annular Space or Vault Sensor. Model: 0 ❑ Annular Space o ult Sensor. Madel: Piping Sump/Trench Sensor(s). Model: ,e�cl$ / 13 Piping Sump/Trench or(s). Model: ❑ Fill Sump Sensors}. Model: ❑ Fill Sump Sensor(s). Model: 13 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. odel: ❑ Electronic Line Leak Detector. Model: ❑ Electronic bine Leak Detector. M ❑ Tank Overfill/High-Level Sensor. Model. ❑ Tank Overfill/High-Level Sensor. Model: ❑-Others i ui ment and model in Section E on Pae 2 . Other s if ua rh[2nt and model-in�ioPa Dispenser ID: j Dispen ID: RI Dispenser Containment Sensor(s). Model: ❑ Dispense ntainment Sensors). Model: ❑ Shear VaIve(s). l� I-S�'+ ❑ Shear Valves . ❑ Dispenser Containment Floats and Chain (s). ❑ Di user Contain nt Float(s)and Chain (s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: c ❑ Dispenser Containment Sens �Model:❑ Shear VaIve(s). I 'g—j ya 0 ❑ Shear Valve(s). ❑ Dis nser Containment Floats and Chains : ❑ Di enser Containment Floats and . Dispenser®: Dispenser ID: Jill,DispenserContainment Sensors). Model (- fi Q Dispenser Containment Sensor(s). Model: ❑ Shear Valves}. jam, j 2c� `(/ ❑ Shear Valve(s), ❑Dispenser Containment Floats and Chain (s). Cl Dis eraser Containment Floats 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 fti•as inspected/serviced in accordance with the rnnnufacturer_' 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 alcf attached a copy of the report;(cI Ck all that gpply): UI-System set-up r Iii to ,re Technician Name(print) Cfjr^/�C' ss� Signature: Certification No.; License. No.: # 7YJ Testing Company Name: ` 2 i t C ii �i� Phone No.-.(go 0 )AW - y Site Address:73D kt, M/mi s U Luk / Date of Testin Servicin 10(o Page I of 3 03101 Monitoring System Certification