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MON ,ORING SYSTEM CERT ICATION . .,r Use By All Jurisdictions Within the State of c_.alifornia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 3, 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 each monitoring 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 systems within 30 days of test date. �- uuu._ Facility Name: �' Y�— <� Bldg. No.: Site Address: ) �rJC� ' City: �e7d-� Zip: Z,_S Facility Contact Person: J /j t. Contact Phone No.: ( ) Mak,-:'Model of Monitoring System: �/�'�Q£� �pp j EZS_-3�_d Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check:the appropriate boxes to indicate specific equipment inspected/serviced: n Tan D. n L Tank ID: In-Tank Gauging Probe. Model: (� /D 7 gtTank Gauging Probe. Model: 7 U -10? C nular Space or Vault Sensor. Model: (� `l K U-'{ZD Annular Space or Vault Sensor. Model: Q` 7 y?fU - 1' Piping Sump/Trench Sensor(s). Mo el:i 1 24 O - L�Piping Sump/Trench Sensor(s). Model: '7 i ❑ Sump Sensor(s). Model: �a ❑ FA I Sump SenSor(5). Model: ET Mechanical Line Leak Detector. Model:OU( �jet%/s 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. Modei: ❑ Other(specify eauinment type and model in Section E on Page 2). ❑ Other(specifv a uipment npe and model in Section E on Page Z). Ta ID: Tank ID: a n- Gauging Probe. ModeI; D In-Tanti Gauging Probe. Model: !KPAnnular Space or Vault Sensor. Model: c-7 le?Y34b-'y ❑ Annular Space or Vault Sensor. Model: iping Sump/Trench Sensor(s). Model: "�O- ❑ Piping Surtp/Trench Sensor(s). Model: 03 FA Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: J 4echanical Line Leak Detector Model: ❑ ;Mechanical Line Leak Dere:or. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Dc:,--.,or. :Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Levei Sensor. Model: ❑ Other(s ecify eoui Pment"c and model in Section E or,Page 2)• ❑ Other(specifv equi mere t��e and model in Section E on Page 2). Dispenser ID: 3 a-l/ Dispenser ID: s4 6 ❑��ispenser Containment Sensor(s). Model: ❑ spemser Containment S^sor(s). Model: �,islmear.Vah e(s). ��g'' ��ear Valve(s). Dis enser Containment Float(s)and Chain(s). Q'Disaenser Containment Ficat(s)and Chain(s). Dispenser ID: T 4-u Dispenser[D: ❑ Dispenser Containment Sensor(s). Model: Cl Dispense:Containment Sensor(s). Model: VShear Valve(s). ❑ Shear Valve(s). 9/Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Fleat(s)and Chain(s). rnenrncP,�jtl DPsp trser 1DI: ❑ Dispenser Containment Sensor(s). Model: El 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). •!f the facility contains more tanks or dispensers,copy this form. Include information for every tank and disperser 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 Certirication 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 apply): ❑System set-up El t Al istory'-leportTechnician Name (print) Signzture: !� Certification No.: S/ `� License. No.: v Testing Company Narne: �lt�/Q�"1/7t � / 7,;F4)A Ze_ �T < Phone No.:� Site Address:' 1130?( ( 3U $ `l Si-¢C i �/`� `�5.�1 ��%Sy Date ofTestirg/Servicing: Page 1 of 3 03;01 :Monitoring System Certification