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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chanter 6.', Ueaiih and Safety Code,-,Chapter J6, 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 remit must be orepared` for each monitoring system control panel by the technician who performs the work A copy of this toren must be provided to the tank system ownerioperator, 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 Facilitv Name: Bldg. No.: Site Address: zS— 1 ��r'��G(G City: y-��< L°�nr7,-- _ Zip: SIS j� Facilitv Contact Person: Contact Phone No.: LiLs_) `�k:Z- ©�rj Make./Niodel of Monitoring System: Date of Testing/Servicing: j B. Inventory of Equipment Tested/Certified Check thea nate boxes to indicate flc eun' went sec-Aced: T• ID: 1Zu( 'rank ID: S�1 L— 1 Tank Gauging Probe. Model S G Lje 3 - ?3L% "-Tank Gauging Probe. Model nuiar Space or Vault Sensor. Model: 0 75 4?46 -'Y6 9 Annular Space or Vault Sensor. Model: CJ)4 3'�U <FOSr ii Piping Sump/Trench Sensor(s). Model: CJ7` �`7 U 12 Cy C/Piping Sump/Trench Sensor(s). Model: e, t-(3i 6 ?d Y ❑ I Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model iechanical Line Leak Detector. Model: (Mechanical Ltte Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill i High-Level Sensor. Model ❑ Tank Overfill i High-Level Sensor. Model: ❑ Other(specify ' ipment type and model in Section E on L.E 21. ❑ Other(specify ettuitmtent=and model in Section E on Pave 2). Tank ID: 7':�)c C Tank ID: ❑ In-Tank Gauging Probe. Model: S'1 C G j- � ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 6�g 4i.2 QU-'10 T ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model:0 )cC-t 3Jy aZ ❑ Piping Sump/Trench Sensor(s). Model: ill Sump Sensor(s). Model: ❑ Fill Su-mp Sensor(s). Model: Mechanical Line Leak Detector. Model: l(6 -05 E ❑ Mechanical Line Leak Detector. Model: l ❑ Electronic Line L--ak Detector. Model: ❑ Electronic Line Leak Detector- Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other Nuinem and model in Section Eon Page 21. ❑ Other(spect equiErarrit=and model in Section E on Page'_). j� Dispenser ID:_ 4- - Dispenser ID: C3 Dispenser Containment Sensor(s). Model: ❑ Dgspenser Containment Sensor(s). )Model: X11-6ear Valve(s). t��w valve(s), 2"bispenser Containment Float(s)and Chains). eDispenser Containment Float(s)and Chain(s). Dispenser ID: 4- --- Dispenser ID: 7 Z3 Dispenser Containment Sensor(s). Model: �❑ pensee Containment Sensor(s). Model: Shear Valve(s). &&ear Valve(s). i �Dis nser ContainmentFloat(s)and Chain(s). Dispenser Containment Floats)and Chain(sl. Dispenser ID: Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear u31ve(s). ❑ Shear Vaive(s;. i :]Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containmcnt Float(s)and Chain(s). :B 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 inspeetediservieed in aceerdanee with the manufacturers' guidelines. Attached to this Certification is information (e g, manuraciurers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout or monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy or the � repor- chec all:hat apply): :1 . System set-up 0 AJ2rm histo )repgrt •� �- Technician dame(print): t� 1 4= r.S Signature:--2—a..< Certification No.: �/ �f License.No.: Testing Company Name: / c=Fi" ;'i Jc �/f `- �` r Phone No.:{ � �F )6, 6.0 ' 7 Site Address:_��( j ate of TesungiServicing: is L(iJL- Page U3:I I W r L Z fW £O 03101 Monitoring System Certification 3010':33 h"t-."