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FEB -04-2009 20:00 Service Station Stystems 408 938 8888 P.02 Monitori System Equipmen ' `erti�tfeation �, se By All J'urisdiclions Within The State of Ca ornia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for eaciimanitoring 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 agency regulating UST system within 30 days of test date. A. General Information Facility Bldg. No.. 2-6 0 a Site Address: �? (.t% L ( � _ City: zip: Facility Contact Person: Net 3 Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Servicing: B. Ittventory.of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/scrvieed; Tank ID• - I - Tank ED, 9 5 - Z_:_ ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: ❑ Annular Space ar Vault Sensor. Model: p Annular Space or Vault Sensor. Model: ❑ Piping Sump C Trench Sensor (s). Model: _ ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: [_l Fill Sump Sensor (s). Model: p Me arca! lane Leak Detector. Model: ❑ Mechanical Line beak Detector. Model: EI -Electronic Line Leak Detector- Model: y 1381actronic Line Leak Detector. Model: -- ❑ Tank Overfill \ High -Level Sensor- Model: _ _ ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other( specify equipment type and model in Section Eon Page 2)• t] Other ( Specify equipment type and model in Scetion E on Page 2). Tank ID• Tank ID: q f ❑ In - Tank Gauging Probe. Model' ❑ In - Tank Gauging Probe, Model: L) Annular Space or Vault Sensor, Model: Cl Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor.($), Model: d Fill Sump Sensor (s}. Model: [] dv�echanical i.ine Leak Detector Model: ❑ Mechanical Line Leak Detector. Model: lectronis Line Leak Detector. Model: `l "lectronic Line Leak Detector. Model: F� [I Tank Overfill l High -Level Senor. Model: ❑ Tank Overfill \ High -Level Sensor, Model.- _ ❑ Other ( specify equipment type and model in Section E on Page 2). [j Other ( specify equipment type and model in Section B on Page 2). Dispenser ]<Dt Dispenser ID: _ ❑ Dispenser Containment Sensor (s). Model: p Dispenser Containment Scnsor (s). Model: p Shear Valve(s). . ❑ Shear Valve (s). p Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID- ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). 13 Shear Valve (s)- ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser M Dispenser ID: [3 Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s), ❑ Shcar Valve (s). ❑ Dispenser Containment Float (s) and Chain (s� ❑ Dispenser Containment Float (s) and Chain (s). *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 was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the;II ,,11 (etke/cx�cll that apply): d System set-up ❑ Alar histo report � Technician. Name (rrint)�Pva W t�1�z �JO4) Signature: Mfg. Cert.#.: O ICC# License. No.: 485184 -sting Company Name: Ser. Sta, SYS. Phone No.: (408) 971-2445 _ Site Address: „;.,� v S�. ,` � Date of Testing/Servicing: