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t MONIDRING SYSTEM CERTIF*TION For Use By.4HJurisdictions Within Ihe.Slate of California Authority Cited: Chapter 6.7, Health and Sir/ety Code; Chapter 16, Division 3, Ti/le 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 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 oftdt date. A. General Information / Facility Name: A} IZA17- /'p OD e/' T/vela Bldg.No.: Site Address: 'fJ13�3 W. City: !AM'Tb Zip: 952 Facility Contact Person: SContact Phone No.:( 333—Z974-7— Make/Model of Monitoring System: F�E� Date of Testing/Servicing: 1/17 B. Inventory of Equipment Tested/Certified Z60 Check the appropriate boxes to indicatespecific equipment inspected/serviced: Ta cID: TanklD: -Tank Gauging Probe. Model: C.4P ❑ In-Tank Gauging Probe. Model r pular Space or Vault Sensor. Model ❑ Annular Space or Vault Sensor. Model: j Piping Sump/Trench Seasons). Model: O8 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Seasons). Model: ❑ Fill Sump Sensor(s). Model: )21`1vteclianical Line Leak Detector. Model:–M4—D7-000 ❑ 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: ❑ Other(specify equipment ty a and model in Section E on Page 2). ❑ Other(s eci equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: El In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 13 Piping Sump/Trench Sensor(s). Model: 1] Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model- El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Mo ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif a ui ment type and model in Section E on Pa a 2). Other(specify a ui ment a and model inNonPage . 7enser ID: 9 4t /0 DispenserlD: ispenser Containment Seasons). Model: 9O'Dispenser Containment Sensor(s). Model: eb ,6Shear Valve(s). L,sShear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: /1'f' Dispenser lD: PRr Dispenser Containment Seasons). Model: 9p 25 ❑ Dispenser Containment Sensor(s). Model: shear Valve(s). - ❑ Shear Valve(s). ❑ Dis enserContainment Floats)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dipenser ID: / Dispenser ID: Dispenser Containment Sensor(s). Model: 'ZOS=S Cl Dispenser Containment Sensor(s). Model: .Shear Valve(s). 13 Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s). ElDispenser Containment Float(s)and Chain(s). -Ifthe 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 equ�ip eat. For any equip fent capable of generating such reports,l have also attached a copy of the report•,(check all Urn/applv): r S stem set-up ' tory report Technician Name(print): - AWg IVtMMO Signature: Certification No.: 110S License.No.: 04 - 167 (o Testing Company Name: AGCO-R/�- TEST � Z e�q Phone No.: o9 ) 7'r,7/ 00l/-7— Site Address: ZLI3 23 h4vY Date of Testing/Servicing: �'/21, m;z .. .� Page 1 of 03/01 Monitoring System Certification A Results of Testing/Servicing