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MQNI1CING SYSTEM CERTIF ATI ' a 4N 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 perforins the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator trust submit a copy of this form to the local agency regulating UST systems withinf30 days of test date. A. General lnf ation Facility Name: G�E S��✓ ��.c� [�� - Bldg.No.: Site Address: '4Z:)4b W P b� Ln • _ ___ City: Zip: Facility Contact Person: _._J;,17j „s Contact Phone No.: (o ar_)J%2-- X746;6 2 :' Make/Model of Monitoring System: je �C i 1J �?� Date of Testing/Servicing: l It l B. Inventory of Equipment Tested/Certified Check theappropriate hDXCS to indicatespecific equipment inspected/serviced. Tank ID: t�-- Tank ID: - .n-a>�� b {} ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 01 Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: 5 Piping Sump I Trench Sensor(s)_ Model: Piping Sump I Trench Sensor(s). Model:L,&,(-S Fill Sump Sensor(s),. Model: ❑ Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. " Model: C3 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model: pZ Tank Overfill/High-Level Sensor. Model: 6-aL Tank Overfill/High-Level Sensor. Model: ❑ Other(speciLy equipment type and model in Section E on Pae 2). ❑ Other(s ecify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: I Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: J Electronic Line Leak Detector. Modcl: _ ❑ Electronic Line Leak Detector, Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and mode(in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser 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 Chains). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: I ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s)_ Model: ❑ Shear Valve(s). ❑ Shear Valve(s), ❑Dispenser Containment Floats and Chain(s). 0 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 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 Plot Plan showing the layout of monitoring equipment. For any equipmen able er z such reports,I have also attached a copy of the report; (check atl that apply): ❑ System set-up ❑ Al rm s ry r t Technician Name(print): Signature: Certification No.: License.No.: 'jt-lt-� Testing Company Name: Phone No.: 10 , �J 'Zite Address: 4D4a tg_�5� (I-,. Date of Testing/Servicing: /eF, Page I of 3 Certified by: 03/01 Monitoring System Certification Scott Co. of California Contractors License 4 184480 510.895.2333 ext. 385 Date: