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MONI4UNG SYSTEM CERTIFIATION Far Use By All Jurisdiclions Within the State of Cali arnia 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 segarate 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 of test date. A. GeneralIn4matipn Facility Name: _ /c t 4 1- t y Bldg.No.: Site Address: t•{tb 13t7 S 6 44d Y 17 City:- a r,' � Zip: L Facility Contact Person: &A1 Contact Phone No.: ()01 q3-;Ly3 S Make/Model of Monitoring System: (/2e(.(e( h LS3s d Date of Testing/Servicing: lj. 17/e7 B. Inventory of Equipment Tested/Certified Check the gooropriote boxes to Indicatespecific equipment Ins ected/serviced: . Tank ID: S__7 Tank ID: 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 11 Piping Sump/Trench Sensor(s), Model: R Piping Sump/Trench Sensor(s). Model: ��u3 gra-723 O Fill Sump Sensor(s). Model: (S Fill Sump Sensor(s). Model: 71W750`3.7-3 • Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: • Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: • Other(specify equipment a and model in Section E on Page 2). O Other(specify equipment a and model in Section E on Pae 2). Tank ID: "( 1 Tank ID: 0 In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 01 Fill Sump Sensor(s). Model: 7A 3%1 -3 2k 0 Fill Sump Sensor(s). Model: • Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: ❑. ElectronidLine Leak Detector. Model: -'� -❑ Electron'ic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment a and model in Section E on Page 2). O Other(specify equipment a and model in Section E on Pago 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). O Shear Valve(s). El Dispenser Containment Float(s) and Chain (s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: • Shear Valve(s). O Shear Valve(s). • Dispenser Containment Floats and Chain (s). 0 Dispenser Containment Floats and Chain (s). Dispenser ID: Dispenser ID: • Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: • Shear Valve(s). O Shear Valve(s). •Dispenser Containment Floats and Chains . O Dispenser Containment Floats 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 equipment a able of generating such reports,I have also attached a copy of the report;�(ch��ec�k�all that th�at I CV system set-up l A m h tory report Technician Name(print): � /) /(pt f- Signature: Certification No.: 3� 2 Y& License.No.:_433159 Testing Company Name;_B.Z. Service Station Maintenance Phone No.:(_916_)_37I-2380 Site Address: 630 Houston Street W.Sacramento,CA 95691 Date of Testing/Servicing: �f 3 Page 1 of 3 03/01 Monitoring System Certification