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r MONaM ATION /sR � O All Jeu•isdiclions liilhirt the.S'Inle of Cn(ija'nia ` Atuhority Cited: Chupler G.7, Health ami5'gfcty C'oc/e; Chrrplcr/G, Uh,i.sion 3, Title 23, Cnlijorniu Code of&e nihilions 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 performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operato6oi5iist submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information -7 Facility Name: -- _ �� `a�Q�' '" FO Bldg.No.: Site Address: jq �7 (y city: Zip:Zip: ZZU Facility Contact Person: NJ 6 \ Contact Phone`No.: (2-09_) 2a:- - Make/Model of Monitoring System: �P_�C )F�9 � CPL -i'L`7')' C> Date of Testing/Servicing: S. Inventory of Equipment Tested/Certified Ched,the appropriate boxes to indicates eciric ui ment ins ected/serviced: Tank ID: Tank 1D: In-Tank Gauging Probe. Model C ❑ In-Tank Gauging Probe. Model: PAnnular Space or Vault Sensor. Model: I)7 f-1 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model:7 rX�, ❑ Piping Sump/Trench Sensor(s). Model: L3 Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s).. Model: Mechanical Line Leak Detector. Model:L!7 Z000 ❑ Mechanical Line Leak Detector. Model: (7 Electronic Line Leak Detector. Model: 13 Electronic Line Leak Detector. Model: C3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ElOther Is cify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 13 Piping Sump/Trench Sensor(s). Model: (3 Piping Sump/Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: (3 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: (3 Other(specify a ui ment type and model in Section E on Page 2). 13 Other(seecify equipment t e and model in Section E on Pae 2). Dispenser ID: f 10 Dispenser ID: ( 'r i (' ❑ Dispenser Containment Sensor(s). Model: 7 OA?) ❑ Dispenser Containment Sensor(s). Model: 7 L3 Shear Valve(s). ❑ Shear Volve(s). l3 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: I ( t i z Dispenser ID: ❑ Dispenser Comment Sensor(s). Model: - 7 V ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment oat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: rJLjDispenser ID: 13 Dispenser Containment Sensor(s). Model:_ 2_C7� ❑ Dispenser Containment Sensor(s). Model: Q Shear Valve(s). (3 ShearValve(s). ❑Dis nser Contaimnent Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include infor_mat�ion for every t�ankyp9nd dispe s r at the " C. Certification - 1 certify that the equipment identified in tkTs docu(�pcnwaSYns ecte �tcced`in nccor�gk/h the manufacturers' guidelines. Attached to this Certification is information (e.g. manufactumrs' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any eq mpment capable of generating such reports,]have also attach d a copy of the report;(check all that app(r): ys t s t tAlarm higtory report Technician Name(print): Signature: �}�CCCCCC'sj! tfs.� lr 1 Certification No:: r� License.No.: 9U /�4 / Testing Company ''Name: iFr�r[11�� ' e�j Phone No.:( Off 7�4-0/)02- Site Address:�•�3Z�i 1tW1� C�ON Date of Testing/Servicing:Q-j_/LEL/-00L Page I of 03/01 Monitoring System.Certification D. Results of Testing/Servicing