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MON.- ORING SYSTEM CERTWI-ATION For use By All Jurisdictions Within the State of California Authorin-Cited: Chapter 6.', Mealth and Safer- Code; Chapter 16, Division 3, Title 23. California Code of Regulations This form must he used tc document testing and servicing of monitoring equipment. A separate certification or report must he prepared for each mortitorinf� system control panel by the technician who performs the work. A copy of this form must be provided to the taut; 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. General Information Facility Name: 1 621.l e G` BIdg. No.: Site Address: 1 Jf f��a C_�' ' kl !� ° '? City: /.CU c i Zip: _ Facility Contact Person: Contact Phone No.: %�/lr��l� ��/ � Make/Modei of Monitoring System: i/�L 0C1' fi c, t -L S 'N6 Date of Tesring/Servicing: B. Inventory of Equipment Tested/Certified Check the app=ri2te boxes to indicate s fiement serviced: Tank IR KEDD: �n L Tank Gauging Probe. Model: t�J Tank Gauging Probe. Model:Z pular Space or Vault Sensor. Model: I i 1 4nular Space or Vault Sensor. Model:7`t`�yYd t/Z6 2'Piping Sump/Trench Sensor(s). Model: Sump/Trench Sensor(s), Madel:Q>`7�(7Ir ZUSC ' zi yill Sump Sensor(s). Model ❑ hill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: L 1d I[f U 8'Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector" Modet: ❑ Electronic Line Leak Detector. Model: �t ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv ui anent t and model in Section E on Page 2). ❑ Other(s ecifv MiRment tvE and model in Section E on Page'_'). Tt.ID: ,) r) . c cr>e- Tank ID: ' G Tank Gauging Probe. Model: 5 ❑ "Tank Gauging Probe. ModeL- nular Space or V autt Sensor. ModeL 1 c`I $O "4t 7-0W/4�nular Space or Vault Sensor. Model: W Piping Sump/Trench Sensor(s). 'Model: CO� et�ATO -20$ ❑ Piping Sump,'Trench Sensor(s). Model: U7 ❑dill Sump Sensor(s). Mod& L1 Fill Stmt/Sensor(s). Model: CY Mechanical Line Leak Detector_ Model: <LIFf►} h C1 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leal Detector. Model: 13 lectronic Line Leak Detector. Model- Ll oder❑ Taal:Overfill/High-Level Sensor. Model: l Tank Overfill/High-Lcvel Sensor. Mode ❑ Other(specify eglupment=and model in Section E on Pae 2). ❑ Other(spec' i mens r3jx and model in Section E on Pace Z). Duliss ID: 1 L1.4 J_ .4- A, , F Dispenser ID: I�{l�ispenser Containn-eat Sensor(s). Model: C''a?`i 3t IN ❑ Dispenser Containment Sensor(s). Model: sd Shear Valve(s). ❑ Shear Valve(s). � ❑ Dispenser Containment Float(s)and Chain(s 1. rO Dispenser Containment Float(s)and Chain(s). Dispenser ID: a Dispenser ID: I ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(si- Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Disp=r Containment Floats)and Chaints). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: I Dispenser ID; ❑ Dispenser Containment Seusor(s). Model: ❑ Dispenser Containment Sensor(s). Model: +❑ Shear v_lve's). ❑ Shear Vaivc(s). 9 ❑Dispenser Containment Floats)and Chain(s). E ❑ Dispenser Containment Fioatts)and Chain(s). 'If the facility contains more tanks or dispensers,copy this form Include information for evert,tank and dispenser at the facility. C. Certification -I eerig-, that the equipment identiried in this document was in;peetedlser-.deed in actwrdanee with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' cher ts) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eq lent. For any equi nt capable of generating such reports,I have also attached a copy of the reprt (ch k that apply):information, 5{stem set-up Al his re rt pt„ o Technician Name(print): C ` cam:f�1.5Signature: !L---S, Certification No.: S 1 1�� License.No.: Testing Company Name: /'? 1Ci,�,` !�t.� K Phone No.: oc; Site Address: do x, ( 3 C'S`f S<>,< Ci4 G Y k 3 J,?Ct SS Date of Testing/Servicing: I l_ Page I of 3 \`�/ `I / I D 03/01 Monitoring Svstem Certification APR 0 1 2003 ENVIRONMENT HEALTH PERMIT/SERVICES