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MONITO.RIN06SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California " —_Authority Cited'Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, Title 23; California Code of This form .must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorint;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 reculating UST systems within 30 days of test date. A. General Information Facility Name: BIdg.No.: Site Address: 8'� 1^ LQV%S C }Sly City: L-e--C Zip: Facility Contact Person: Contact Phone No.:(.20l) 9e3 9)1-10 Make/Model of Monitoring System: T L S — 3 t7 Date of Testing/Servicing: 1,2491 O� B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: g S Te _S _j r"')P Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: — F,Piping Sump/Trench Sensor(s). Model: -79143,M •J-Z 3 ❑ Piping Sump/Trench Sensor(s) Model: O 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: ❑ EIectronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sens r. 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). 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; Cl 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: m Dispenser iD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contaitunent Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ 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), O Shear Valve(s). ❑ 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 Sensors. Model: C3 Shear Valve(s). ❑ Shear Valvc(s). ODispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). lif the facility contains more tanks or dispensers,copy this corm. Include iniotmation 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 equipment. For any equipment capable of generating such reports,I have also attach a copy of the report,(check all that apply): ❑5y�et-up ❑Alarm history report Technician Name(print): aSignature: Certification No.: 4,2 13 ! 1 License.No.: Testing Company Name: �'t#�t'r 'Gin tPn�. Phone No.:( 10_.3.5-) Y-27 7 Site Address: ' IOiJ;Je /�J� t Date orresting/Servicing: IZ/?,O /O Page i of 3 03/01