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Y ' MONITORING SYSTEM CERTIFICATION For Use By AH Jurisdictions Within the State of California Authority Cited Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, 7itte 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equiprnenL A Mparate certification or report 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 ownez/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 Information 4iVacility Namin. Bldg.No.: `RJ Site Address: City: (��• Tip:q5- Facility Contact Person: qJ Contact Phone No.:(" )EST-4116 Make/Model of Monitoring SDate of Testing/Servicing: 6/ / B. Inventory of Equipment Tested/Cerfiried Check thea ' te boxes to indicate "fie equipateat ins serviced: Tank ID: lr7 Tank ID: In-Tank Gauging Probe. Mode]: hs-Tank Gauging Probe, Model: obsutign Annular Span or Vault Setsor. Model: Orf/ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 2C7fi Piping Sump/Trench Sensor(s). Model: -Z jr Q Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical line Leak Detector. Model: f&ZimtJ Mechanical Linc Leak Detector. Model: — Electronic Lim LeakDewor, Model: Electronic Lim Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: r�Q,1ylaf Tank Overfill/IGghdevel Sensor. Model: 74gr7L� Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment ripe and model in Section E on Page 2). Tank m• Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: O Annular Spam or Vault Sensor. Model: ❑ Piping Sump/Trench Seaser(s). Model: (3 Piping Sump/Trench Sensor(s): Model: ❑ Fill Sump Seasor(s). Model: Cl Flu Sump Sensor(s). Model: ❑ Mechanical line Leak Detector. Model: U Mechanical L3he Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Tank Overfill/Ifigh-Level Sensor. Model: O Other(specify equipment type and model in Section E on P e 2). O Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 10 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Semor(s). Model: Shear Valve(s)_ ❑ Shear Valve(s). Dispenser Containmem Float(s)and Chain(s). ❑ Dis Containment Float(s)and Chain(s). Dispenser ID: ZI Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 13 Dispenser Containmesht Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dis nxs Containment Float(s)and Chain(s). ❑ Dispenses-Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Mock: ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Float(s)and Cbain(s). ❑ Dispenser Containmrnt Float(s)and Chain(s). -If the facility contains more tanks or dispensers,copy this forth. 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 uipment capable of generating such reports,I have also attached a copy of the repo (check all apply): System set-up Alarm Vtt y report Technician Name(print): Sr'.xA'R Signature: 2� I Certification No.: 'S�=`j?-;,E.56 yy License.No.: C X J-N-A, Testing Company Name: - . A/ r Phone No jj(R Site Address-. (4470 rdlla;n o` �-, Date of Testing/Servicing: I^.��c l ui'3 IU.oI \lurid�riu��r>trsn Crniliraliuu