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to 1 g�/aysoo,5 MON)TORING SYSTEM CERTIFICATION For'Use By All Jurisdictions Within the State of California Awhim ry Cned: Chapter 6.7, Health and Safer),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 reoon 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 Inforation Facility Name: C1rC. vI-2 " C1 Bldg.No.: 7� Site Address: 1aO(p V-1. 1(f119'f() i Y1 City: §InY,}nom Ziipp�: a Cl ) v Facility Contact Person: O VJilei Contact Phone No.:(ate) 4 r O-Wi MakeJModel of Monitoring System: Vee&, x �1 W r J 5� Date of Testing/Servicing: $/CP 0 B. Inventory of Equipment Tested/Certified Check the apRrEETWIE bOx�to indicates ecifie ESWEMellt irapected/serviced: Tank ID: - Tank 111C 19 In-Tank Gauging Probe. Model: 1:1 In-Tank Gauging Probe. Model: % Annular Space or Vault Sensor. Model: M Annular Space or Vault Sensor. Model: L01 31 Piping Su /Trench Sensor(s). lY Piping Sump/Trench Sensor(s). Model: o g Model: ❑ Fill Sump Sensor(s)'. Model: ❑ Fill Sump lLineSenso(s). — C)(Mechanical line Leak Detector. Model: Qd Mechanical Linc l.ealc Detector. Mode]: 0 ❑ Electronic Line Leak Detector. Model: ❑ ElmEronic Line.Leak Detector. Model: to Tank Overfill/High-Level Sensor. Model: — a Tank Overfill/High-Level Sensor. Model: ❑ Other(s ify equipment type and model in Section E on Pae 2). 1 O Other(specifv equipment type and model in section E on Pae 2). Tank ID: Tank ID: 45 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or V auh�ensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s) Model: O Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model:- -�-�-� ❑ Fill Sump Sensor(s). Model: I Mechanical Line Leak Detector. Model: Fee t t't� t� C3 Mechanical Line l cak Detector. Model: ❑ Electronic Line Leak Detector. Mode: O Electronic Line leak Detector. .Model: > Tank Overfill/High-Level Sensor. Model: — O Tank Overfill/High-Level Sensor. Model: Other(5 'fy equi mem type and model in Section E on Pae 2). ❑ Other(specify equipment ivve and model inSectioUPape Dispenser TD: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: aO �Q Dispenser Containment Sensor(s).716 Model: `df18 Qct Shear V alve(s). Shear V alve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). Dispenser TD: - L Dispenser ID: 1�1 Dispenser Containment Sensor(s). Model: a f14 Dispense Containment Scnsor(s). Mode]: 6t5 Shear Valve(s). 9 Shear Valve(s). ❑ Dispenser Containment Fioat(s)and Chain(s). Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 1 Dispenser Containment Sensor(s). Model: 4i Dispenser Containment Sensor(s). Model: Shear V alve(s). Shear V slve(5). ODispenser Containment F1oat(s)and Chain(s). El 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 manufacturet-s' guidelines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to verify that this information is correctand a Plot Plan showing the layout of monitoring equipment. For any a itipmeni capable of generating such reports.7 have also amched a copy of the rort;(check all th I apply): It System set-up lane his ogy'r 171 Technician Name(print): �Onn\ P OiyynfteJ` Signature: Q J J4 Certification No.: License.No.: � Testing Company Name:�r1A�YtD.�-P_\ �Y1✓\rnYr1QY1AL PhoneNo.:�" ) 890 'b/ p^ / OL,)Address: ,n..i I m� % LY) Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification