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4 MON>,oAJRING SYSTEM CERTIFNe r,TION -2 For Use By All Jurisdictions Within the Slate ofCaliifornia I=iF�th to Sn c) LL��7 t Authority Cited.' Chapter 6.7, Health andSafety Code; Chapter 16, Division 3, Title 23, California Code of RegaiEAjfi lglio s This form must be used to document testing and servicing of monitoring equipment. A separate certific;'olt'' r"i9bFitZuEStSbe 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 agencyenfgulating UST systems within 30 days of test date. General Information Facility aciliyName: � 1 / `45 y 10� -r Bldg.No.: Site Address: 14 /0/4 W AeV City: A) Zip: Facility Contact Person r _ Contact Phone No.:( 2�0cl 'Y86jo/ Make/Model of Monitoring System: QA(4 Q/C[ AXRO Date of Testing/Servicing: 7 B. Inventory of Equipment Tested/Certified Check the appropriate bores to indicates eciric equip meal inspected/serviced: Ta ID: 137 pL- TanklD: � -Tank Gauging Probe. Model 13 In-Tank Gauging Probe. Model: anular Space or Vault Sensor. Model:f� !' ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: X —C ❑ Piping Sump/Trench Sensor(s). Model: 9❑ ill Sump Sensor(s). Model: L3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Syf MCP ❑ 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: prp,ping ther(s ci a ui ment a and model in Section E on Pn a 2). ❑ Other(s cif a ui ment t e and model in Section E on PaeID: R/ OCi7 TankID: -Tank Gauging Probe. Model: ClIn-Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ F'I Sump Sensor(s). Model: - ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:_<J� 1w Z70— ❑ 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 t e and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: T- 'L Dispenser ID: ❑ 'spenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). ❑ Shear Valve(s). Dispense Containment Float(s)and Chain(s). ,(;j O Dispenser Containment Float(s)and Chain(s). Dispenser ID: DispenserlD: rDispenserID: penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). ModA ar Valve(.). ❑ Shear Valve(s). nser Containment Floats)and Chain(.). Qs ❑ Dispenser Containment Floats)and Cha Dispenser ID: penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Modar Valve(s). ❑ Shear Valve(.).Dispenser Containment Float(s)and Chain(.). ❑ Dis nser Containment Floats)and Chai *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 utas 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 equip meat capable of generating such reports,I have also attic ed a copy off tt//ife rcpmt;(c/reek al/that apply): see A&Alartn history report Technician Name(print): �AAjE MIZ D Signature: Certification No.: License.No.: 0 7"/-/to/ Testing Company Name: — Phone No.:6962 ) 76�— O//y_ Site Address: ZVy W• WA,fflfii oll/A Date of Testing/Servicing:� — .. Monitoring System Certification Page] af3 03/01 D. Results of Testing/Servicing