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MONI ORING SYSTEM CERTII'RATION For Use Bv.11l.luriseliclions II'i/hin Ihe,Slule of'Califbrnhr . l ulhorio) C'ifecl: Chapter 6.7, Heallh 111711 &tfeh� C orle; Chapter 16, Division 3, Ti/%e 23, C'crlijbrnict Cocle gf'Reg111alion,r This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorine system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/opek-Oor. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Site Address:_70/ r_ ML7�/1— A44x _City: c Bldg. No.: Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: //j Ts- to -1 B. Inventory of Equilfnient Tested/Certified Check the :appropriate boxes to indicate specific enuinment insnected/serviced- Date of Testing/Servicing: 5 et /0 Tank ID: g7 oG_T Tank ID: A In -Tank Gauging Probe. Model: A,?A6r ❑ In -Tank Gauging Probe. Model: iq Annular Space or Vault Sensor. Model: ,r/S ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: UL -5 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: fia Mechanical Line Leak Detector. Model: STP- Mr 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: ❑ Other (specify equipment ty a and model in Section E on Pae 2). ❑ Other (s ecify equipment t e and model in Section E on Pae 2). Tank ID: p` Tank ID: 'n In -Tank Gauging Probe. Model: MAh ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: kPiping Sump / Trench Sensor(s). Model: to L S ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: RLMechanical Line Leak Detector. Model: F yc -t ✓ ❑ 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 type and model in Section E on Page 2). ❑ Other (s ecify equipment ty e and model in Se on E o Page 2). Dispenser ID: (-t- Z Dispenser ID: -+- IN ;N Dispenser Containment Sensor(s). Model: u LS X Dispenser Containment Sensor(s). Model: 4 S A Shear Valve(s). jk Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3+ -Lf Dispenser ID: Dispenser Containment Sensor(s). Model: Gt L9 ❑ Dispenser Containment Sensor(s). Model: ®- Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 1D: 5 t: Dispenser ID: 4 Dispenser Containment Sensor(s). Model: 411-5 ❑ Dispenser Containment Sensor(s). Model: A -Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). if the ractuty 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 capable of generating such reports, I have also attached a copy of the report; (check all that app/v): IM S t- p R Alarm history report Technician Name (print): Z4we /Vim^.,,j Signature: Certification No.: /403 License. No.: "TH �z� 33a,7 U r 7�� Testing Company Name: �- Phone No.:UDcj )'7-J-/ - 0&.2, Site Address: �IO� �.?�cll'_ Date of Testing/Servicing: 5131 /6 Monitoring System Certification A Results of Testing/Servicing Page 1 of 03/01