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W�TORING CERTIFfCATION For Use By All Jurisdictions Within the State of California Authority.Cit{ed: Chapter 6.7., health and Safety Code; Chapter. 16, Division 3, Title 23, California Code of Regulations This form must fie used to document testing and servicing of monitoring equipment. A separate certification or report most be prepared for each monitoring system control Danes 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: '�A N CY 0,44 u / 1J Bldg. No.: Site Address: ` city: JJ Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: *5 _-Sl-p Date of Testing/Servicing -7/ / B. Inventory of Equipment Tested/Certified Check the avorotiiiate bosei to Indicate snecifie eanioment serviced: Tank ID: l k 14+'6ep�,Db"p Tank ED: Gauging Probe. Model: _ems ClIn.Tanlc Gauging Probe. Model: E3-Tank Annular Space or Vault Sensor. Model: % tVYTO-3®Z ❑ Annular Space or Vault Sensor. Model: 2 -Piping Sump / Trench Sensor(s). Model: WV -3 Y 0 - 3 2 ❑ Piping sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: US-lechanical Line Leak Detector. Model: S7` - �� O Mechanical Line Leak Detector. -Model. ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s a ui mint = and model in Section E on P e 2). ❑Other (s vi nt = and model in Section E on Fa 2). Tank ZI?: �� Tank ID: ha Tank Gauging Probe. Model: zeC1A51'-1 ❑ In -Tank Gauging Probe. Model: �A ular Space or Vault Sensor. Model: -7 F "JO .�S "Z ❑ Annular Space or Vault Seng. Model: 311 -ping Sump / Trench Sensor(s). Model: Z5'�-3 SIT„ -5f-'- ❑ Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 37-00 -%[ Z- 7i ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lute Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (spScify F2uipment = and model in Section E on Pa a 2). ❑ Other (s ui nt = and model in Section E on Page 2). I7ris ID: � _ 2- Dispenser ID: Dispenser Containmcnt Sensor(s). Modal: "79 2`3 �c 3 a`"a ❑ Dispenser Containment Sensor(s). Model: UShear Valve(s). ❑ Shear Valve(s). ID Dispenser Containment Float(s) and Chain(s). ® Dis nser Containment Float(s) and Chain(s). Dispenser ID: -9-K Dispenser ID: Q�penser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: U Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s) and Chain(s). O Dispenser Containment Float(s) and Chain(s). r ID: Dispenw ID: [Dis 13 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �iaear valvefs). ❑ Shear Valve(s). ODispenser 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 idesUned in this document was inspeeted/servieed in aecordanee with the manufacturerss' guidelines. Attached to this Certification is information (e g. manufacturers' cheddists) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring eq�enL For any equi nt capable of generating such reports, I have also attached a copy of the report; (check all that ply): ZISystem set-up =Ah�is:to reA Technician Name (print): ✓ (0 /� �; a� Signature:/7 Certification No.: License. No.:. 4�Zo Testing Company.Name: ¢ �c/G'! C%�o�LtS�adJ j� ��T�� Phone No.:(5�)� 6c: — ` Site Address: til 0 RJZE-T71,), C' Date of Testing/Servicing: Page i of 3 Monitoring System Certification ONO 03/01