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C"tr ti V W�U 'WE";ID MONITORING SYSTEM CERTIFICA T iON �J For U.ve BY A/l Juriscliclions I1'irhin lire Slale of Cal fo✓•nia Awhorily C'ilecl: C'hal-ler 6.7, Heal/h and Safety Cocke; Chapler 16, Division 3, Tille 23, California CoWRc >trf��rl This form must be used to document testing and servicing of monitorinquipment. A se crate ceW �i1}$t2 i t'H s e prepared for each monitoring system control panel by the technician who per orms the work. A copy of this Mf hTiA%fRk("td 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. A. General Information Facility Name: MG •0na Bldg.No.: Site Address: 1 City:(C'5 k ljll` Zip: Facility Contact Person: Trc�IJ Contact Phone No.:(_ ) Make/Model of Monitoring System: 1 L5 G,py P�d U__> (X }` Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui meat ins ected/serviced: Se r i{ e O _NA Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ 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: C3-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 a and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: L3Piping Sump/Trench Sensor(s). Model: ❑ Piping Swap/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 e uipment type and model in Section E on Page 2). ❑ Other(specify equipment tv e and model in Section E on Pape 2). Dispenser 1D: i '7 Z Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). '10—Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 4 Dispenser ID: 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). U�Shear Valve(s). Dispenser Containment Float(s)and Chain(s). 'Q-Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Contaimnent Sensor(s). Model: ❑ 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. Liclude 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 manufacturers' guidelines. Attached to this Certification is.information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipme t. For any equipment.capabl sting such reports,l have also attached a copy of the report;(c/reek all that appJV): ❑S tem set-up Alarm story repot Tec�inician Name(print):EE pF��elix Ramirez Signature. Certification No.: B 3491 License.No. OTTL#08-1740 ICC# -UT Testing Company Name: Phone NoA 2-4 )-)L4 LIy Z 17 Site Address: (-)ia L1_ Date of Testing/Servicing: Page 1 of 03/01 Monitoring System Certification B. Results of Testing/Servicing