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Monitoring 6ystem Equipment Certificatiori`�' `' For Use By All Jurisdictions Within The State of Califomia � -•� Authority Cued: Chapter 6.7, Health and Safety Code; Chapter 16, atision 3, Title 23, California Code of Regulattoip 2 1 2011 This form must be used to document testing and servicing of monitoring egUpment. A separate certification or report must be r; Uj prepared for each monitorine system control panel by the technician who performs the work A copy of this form must be provided,-tvTAN►Y to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system ` VEWr within 30 days of test date. A. General Information Facility Name: _ �Jvwz Bldg.No.: SiteAddress: . � (t.� L"I City: Zip:: Facility Contact Person: 1�c I„ Contact Phone No.: Make/Model of Monitoring System: V a- 1 L\ 3 S--0 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID�.L ❑ In-Tank Gauging robe. Model: ❑a�Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model' ❑ Piping Siunp\Trench Sensor(s). Model: ❑ Pill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: EWechanical Line Leak Detector. Model: WOOS ❑ Mechanical line Leak Detector. Modc1 El 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 mens P�1'UNiP type and model in Section E on Page 2). Tank ID: Tank IDL ❑ In-Tank Gauging Probe. Model• ❑ In-Tank Gauging Probe. Madel; ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(a)and Chain(s). ❑ Dispauer Containment Float(s)and Chain(s). Dispenser IDs Dispenser ID: ❑ Dispenser Cona;nment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). [i Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Fpenser ID; ❑ Dispenser Containment Sensor(s). Model:_ Dispenser Containment Sensor(s). Model: ShearValve(s). Sheer Valva(s). C] Dispeasex Containment Float(s)and Chain(s). Disi�easer Containment Flcat(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.include information for every ru+_k 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.mannractrres*checklists)necessary to verify that this information Is correct and a Plot Plan showing the layout of monitoring equipmenf.,.For any equipment capable of generating=ucL reports,I have also attached a copy of the; (check all that apply): ❑ Systt;a set-up ❑ Al history report Technician Name(print): efyajf _ . Ignature: _ Certification No.: �. �� License, Testing Company Name: Ste, ��,�,�_ � ` Phone No.: Address: (.�'l� ('� . v-e �� , ]� Date of Testing/Servicing: