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MONITORING SYSTEM CERTIFICATION For Use By cA,.ltiurisdictimts Within the Stare of California dathority Cited:Chapter li Z Reolrh and SOleu Code:Chapter 1 b•Division 3,Tide 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or tenon trust he oreoned for each monitoring system control pawl by the technician who performs the work. A copy of this form most be provided to the tank system owner/operator. The owner/operator most submit a copy of this form to the local agency regulating UST,systems within 30 days of test date. A. General Informal _ Facility Name: /�(-- �)�[ �` y.. ,�„ Bldg.No.: Site Address: J7- ' / ! )��Ml%-f` A✓/� City:r /3 iLC- Zip: 4s334 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Date of Tecting/Serweing: _-9-1_1—Oz B. Inventory of Equipment Tested/Certified ❑neck th,3powwite boxes to indicate 7c_ - men/' tedtservicad: :Took ID: ' Tank ID: d7iln-Tawe Gauging Probe. Model: 9-In-Tank Gauging Probe. Motel: trla� AkAnnular Space or Vault Sensor. Model: CI •+rh T 0,Ana41ar Spacca-Vaah SeascT. Model Ft....1/ D Piping Sarno I Trench Smsor(s). Modd: 0Piping Sump/Thmch Sensor(s). Model: u rdt sump Seasor(s). Mtakt: a Fill Sump Seuso*)- ModeL ' Mechanical line Leah Detector_ Madel 'F.ct #�-Mechanical LioieaFDetedur- Madel: L Zono7 Q Plecucaak line Leak Detector. Model: ) Q Elecvonic Line Leak Derectm- model- ID odel❑Tank Overfill I High-level Sensor. Mode): Sit Tank Overfill I Ifign-Level Setrstrc- Model: O Other(specify eoummew!uc and model in Section E on Pw 2). Q Other( equipment and model in Section E on Pa ? Tank 1D. Tank IIT Ga In- .0 hi-Tank rgingPtobe ModaL ❑ tn-TaukGatgLag Probe. Model!yG/D-Annolar Space or V ult Scutum. Model Q Annular Sparc mVault Surxs. Model: M1 ❑Piping Sop I Treads Seusor(s). Model; Q Piping Sump/Trench scowl's). Model: Q rill Sump Smsa(s). Model: Q Fih Sump Smsor(s)_ Model: 4(a MccIvnical Line Leak Detector. Mold: Q Mechanical Line Leak Detector. Model: Q EVeananic Link LsakD�eaor- ModcL Q P)ectronicLinelxaicDetertot. 1,10ad: Q Tank Ch-a fill 1 High-Level Sensor. Model ❑Tank Overfill I High-Leve)Senwr_ Model I- Q Odtcr •eaui t and model in Section E on Pane 2). Q Ohba(s •dirt and rode)in Section E on 2). Dispenser ID: I-Z met•ID: ._ ❑Dispenser Containment Seasor(s)- Model' (3 DLpwscr Centaitmua SmmKs). Model: 'W.Sheat Valve(s). tV.^gt"Shear Valve(s). Dis er Containmea[Float(s)and Chaintt)- -jdDspcuser Contxinmcat Flom(s)and Chants). Dispenser LD: -4 DIspenserID: Q Dispcuser Comaimtem Sensor(s). Model: Q Dispenser Cantainnuvt Seasor(s). Model! 7 ja Shear Valve(s)- t'3 Shea Vavets). BZDi .sa Containment Flo 1 noel Chain(s). ❑ G a Containment Fl s)and Chain{s). Dispenser ID: '�_C Dgg ❑ Dispeosar Contai®ea[Sensor(a). Madel: ❑Dispenser Containacm sensor(s). ModeL t Shear Vahe(s)- ❑Shear V211x(51 chaDisaensrsCnn[aiument Fioat(sl and Cirain(s) ¢ t7 Dispen Can.-a t tlou()cad O..() if the facrbtycontains more tanks or dispensers.copy'Ms form- include mimmation for every tank and dispenser ar the facility. C. Certification-I ecttify that the equipment identified in this dounneat was inspectedfserviced in accordance with the manufacturers' guidelines. Attached to this CertiLcation is information (eg. memm[aotnrus' chwkhsrs)ae ewary to vcn[y that this mforanation is correct and a Plot Plan showing the 6vuat of moaltoring equTnent. For any npahie of genaatmg such tgarts,I have also atlached amp)•of the (c(iedc all ). Q systemise.""' ystem set-up Lr!Maim hior3'report Technician Name(punt):7rt i Si e.""' Certification No.: No.: License No.:�O-1 o S 2 Tesdng Company Name:—.-7Tf+I/<-' - Site 6 Six Address: Date of Testmg/Servicing:_I Page I of3 03101 A4onitanting5ystetn CechCtca{ian