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M10r, 410RING SYSTEM. CERVI OATION T -or Ilse R), -III hn•isdictions Within the •Slide (?I'( '(11ifi)rnh I I mlhorilp C'ile(f C'hctpler 6. ?, f%ulth otic%Su/c /v C.'o(le; C'htiper 16, Division 3, Title 23, C air fnrnia Code of Re;�;rrlu/ioil•s 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 seem 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. Cenertt Facility Name Site Address: Facility Cont, Make/Model a B. Inventory of Equipment Tested/Certified Check tile appropriate boxes to indicates ecift ee ui went inspected/serviced: Bldg. No.: 5-roCe_-roPj Zip: .15zo7 .ontact Phone No.: ( Zoq ) tS5_ Z_jOO Date of Testing/Servicing: ID: ®G`i' Tank ID: 6 EtIn-Tank Gauging Probe. Model: / A In -Tank Gauging Probe. Model•Annular [Tiink Space or Vault Sensor. Model: Al Annular Space or Vault Sensor. Model•Piping Sump / Trench Sensor(s). Model: O W Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Al Mechanical Line Leak Detector. Model: 57P•/ -f . Mechanical Line Leak Detector. Model: 9f10 2 ❑ 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 ty e and model in Section E on Pa =e 2). ❑ Other (specify e ui menit type and model in Section E on Pae 2). Tank ID: R 1 e>c-- Tank ID: In -Tank Gauging Probe. Model f ❑ In -Tank Gauging Probe. Model: MQ Annular Space or Vault Sensor. Model: O ❑ Annular Space or Vault Sensor. Model: IQ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: AZ Mechanical Line Leak Detector. Model: STA—MCA ❑ 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 (s ecify equipment ty a and model in Section E on Page 2). ❑ Other (specia equipment t e and nnodel 'n Section E on Page 2). Dispenser ID: / 4-Z Dispenser ID; s¢ w Z)/e ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). �❑{ �L`LShear Valve(s). ULDispenser Containment Float(s) and Chain(s). Dis enser Containment Float(s) and Chai (s). Dispenser ID: Dispenser ID: -7 T-6 r.� b®,_ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: k! Shear Valve(s). Shear Valve(s). A 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: alve s . ❑ Shear Valve(s). on auunent Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). -pit 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 equi ment. For any equip ent capable of generating such reports, I have also attached a copy of the report; (check aH thal app1P): SxsIt e Alarm history report Technician Name (print): =,p AL23"Z' Signature: ;M ,2- or Certification No.: /493 License. No.: T- p � � ^ �-�. •tom—� - I �i Testing Company Name: _ Tesr Phone No.:(po_)''_y-/ - 611,2.__ Site Address: OL1 Date of Testing/Servicing: /0 T� Monitoring System Certification A Results of Testing/Servicing Page I of 3 03/01