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UU MONI"SlblRING SYSTEM CERTIFIbATION , For Use By All Jurisdictions Within the.State of California }Ax. ci .r LLO7 Authority Cited: Chapter 6.7, Health and Sa/ety Code; Chapter 16, Dirision 3, Tide 23, California Code of Reg:du/iaLs . , tEALi H This form must be used to document testing and servicing of monitoring equipment. A separate certification or reporf\A{nbe prepared for each monitoring system control panel by thetechnician 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-i-,3gulating UST systems within 30 days of test date. Fa General Information 527 W /Sy 4ej r Facility Name: '/'/ "� �/� �"( Bldg.No.: Site Address: ZT r {1/. L1 01016'/ mik-y City: �'.Tor�L OAJ Zip: Q Facility Contact Person ,•/ Contact Phone No.: Make/Model of Monitoring System OA 46t Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate hoses to indicates ecific a ui ment inspected/serviced: Tupk ID: 87 QL7 Tank ID: ,09n-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe. Model: anular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Aff Piping Sump/Trench Sensor(s). Model: /3X -L( ❑ Piping Sump/Trench Sensor(s). Model: ❑ ill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: SIP ml P ❑ 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: 13 Other(specify equipment t e and model in Section E on Page 2). LI Other(specify equipment t e and model inXonPage T Ta aA ID: 9/ O!i'T Tank ID: In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: anular Space or Vault Sensor. Model:--SK U/( — ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model:_'JjJC [iS ❑ Piping Sump/Trench Sensor(s). Model: ❑ F I Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: S iy LO ❑ 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[ e and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 11- 7-- Dispenser ID: ❑ 'spenser Containment Sensor(s). Model: ❑ Dispenser Containment Senors). Model: tear Valve(s). ❑ Shear Valve(s). Vis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: �- Dispenser ID: ❑Qispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ear Valve(s). LIShear Valve(s). AffDis nser Containment Float(s)and Chain(s). Q.S ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Senors). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis nser Containment Float(s)and Chain(s). L3Dis tenser Containment Float(s)and Chains . Hf the facility contains more tanks of 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 equTmeat capable of generating such reports,t have also attat•Jyed a copy oft/, report;(check all that apply): se _ A"larm history report Technician Name(print): )C ALAE /�//MMD Signature: Certification No.: License.No.:_ Op Testing Company Name: — Phone No.:(,, 7/jZ .00r/.2__ Site //.2__ Site Address: W,&gb lAtA Inky Date of Testing/Servicing: 'Jf /_/.0 7 .� Monitoring System Certification Page 1 of 03/01 D. Results of Testing/Servicing