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MONA RING SYSTEM CERTIFPATI©N For Use By All Jurisdictions Within the State of California Authority Cited. Chapter b.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 'itis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must bepreparedfor 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 Inf mation Facility Name: -G S%rc�P,u _ ."� ma _ Bldg.No.: Site Address: 404{] �,, City: �y� j� zip: p Facility Contact Person: tS Contact Phone No.: C! Make/Model of Monitoring System: \,Om a.�ii a,5- 1b Date of Testing/Servicing: I B. Inventory of Equipment Tested/Certified Check the 1 ro riate boxes to indicatespecific a ui meat inspected/serviced: Tank ID: 1 Tank ID: L-VtC., ❑ In-Tank Gauging be. Model: ❑ In-Tank Gauging Probe. Model: XAnnular Space or Vault Sensor, Model�gt4y—j.0—QZ Annular Space or Vault Sensor. Model�QL Pib__qzo is Piping Sump/Trench Sensor(s). Moder-)GGu�i Piping Sump/Trench Sensor(s). Model: 3 C3 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Madel:Rl '4AKElectronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: El Other(s ecify equi meet type and model in Section E on P2ge 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ N-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: D Piping Sump/Trench Sensor(s). Model: 9 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: J Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Other(specify equipment type and model in Section E on Page 2). ❑ Other(speeif equipment type and mode] in Section E on Page 2). Dispenser ID: � E2 Dispenser ID: ❑ Dispenser Containmen Sensor(s). Model71rILA ( ❑ Dispenser Contai eru�i nt Sensor(s). Madel��JW 7� AS's E2 Shear Valve(s), ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID; Dispenser ID: 0 Dispenser Containment Sensor(s)- Model:__ -It'jj—moi ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dis eraser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser C6ntainment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this farm. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identified in this document was inspectediserviced 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 re ort- check all that apply): System set-uprl -�rm ep Technician Name(prii Signature: Certification No.: CXR -kir;C{ License.No.: Testing Company Name: Ga~[t Phone No.:(�l d -S re Address: 4j�gz V Leo Ln . Date of Testing/Servicing: �01�7 IiJ Pape I of 3 Certified by: 03/01 Monitoring System Certification b Scott Co. of California Contractors License# 184480 510.895.2 33 ext. 385 Date: '