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0 RECOVED MONITORING SYSTEM CERTIFICATION MAY 3 1 ZOOZ For Use By All Jurisdictions Within the State of California ALTIi Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California UTj PERMIT/SERVICES This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must berep Dared 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. A. General Information Facility Name: � Bldg. No.: Site Address: �" �fm►) �" City: Zip: Facility Qontact Person: Contact Phone No.: () Make/Mode of Monitoring System: 6'32 Date of Testing/Servicing: l B. Irfventory of Equipment Tested/Certified Check the annrooriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: ❑ In -Tank Gauging obe. Model: ❑ In -Tank GauginyProbe. Model: _ Annular Space or Vault Sensor. Model Annular Space or Vault Sensor. Model: {Piping Sump / Trench Sensor(s). Mode : Piping Sump / Trench Sensor(s). ModelAO "'bbi5 ❑ 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:vle. VU--" ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other (s cif a ui ment tY a and model in Section E on Page 2). Tank ID: Tank ID: !•!>AS77�- a: L idn�71 ❑ In -Tank Gauging Probe. Model: _ ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model -I 4 Annular Space or Vault Sensor. Model: 4517 - Piping Sump / Trench Sensor(s). Model"j_jl500"21C b Piping Sump / Trench Sensor(s). Model: 1-5-3 ❑ Fill Sump Sensor(s). Model: — ❑ Fill Sump Sensor(s). Model: I-AWOMfechanical Line Leak Detector. Model: WOy]t ❑ Mechanical Line Leak Detector. Model: Electronic �.ine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment type and model in Section E on Page 2). ❑ Other (s ecify equipment t e and model in Section E on Page 2). Dy'penser ID: Dispenser ID: 2� Dispenser Containment Sensor(s). Model: 3 ❑ Dispenser Containment Sensor(s). Model �A ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: A@ Dispenser Containment Sensor(s). Model-IqLUS130 9 Dispenser Containment Sensor(s). Model: �131bp��►� ❑ 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). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If 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 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 re , I ve also attached a copy of the report; (check all that apply): Adystem set=up od_Alarm history repor Technician Name (print): ghnrFnnt a- Signature: Certification No.: _S��"tAsu License. No.: 184480 CD Testing Company Name: Scott Co. Of CaliforniaPhone No.:( -,in ) R9a,-2-4-n4 3F $ Site Address: �&n Date of Testing/Servicing. / Page I of 3 03101 Monitoring System Certification