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r Lr in rL-uurc rHUt rJL f , r d ✓� - MO A`�'ORIN'G SYSTEM CER.T1kA AT1ON �V For Use By All Jurisdictions Within rite State of California Aurhority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3. Title 23, California Code of Regulations This form trust be used to document tcsdag and servicing of monitoring equipment. ,& kgRilratee certification or regD m'491 tm RreRared for each monitgring system control pa -%g by the technician who performs the work. A copy of this form trust be provided to the tank system .wner/operator. The owner/operator must subrxut a copy of this form to the local agency regulating UST systems within 30 days of test date, A. GeneralInfo,rmittion Q Facility Name: S e J , ✓e �"lyY' p xG' Bldg. No.: Site Address: /9/0 J& -Z � l ±ZLI City: ��'c}-�G�17J>t _ Zip: Facility Contact Person: Contact Phone No.: (=4) &2& — U 9 9 Make/Model of Monitoring System 4' L Date of Testing/Servicing: B. Uventory of Equipment Tested/Certified Check the appropriate boxes to indicate spetihe (.'tlulpment Inspected/scrYi<ed: Tank ID: �' In -Tank Gauging Probe. Model:' C – Tank ID: In -Tank Gauging Probe- •' Modell/ –/0 �Z Annular Spacc or vault Sensor. Model: - r Annular Space or Vault Sensor. Model--. a 7 ?o -3oZ ;'?ipinS Sump / Trench Sensor(s). Model: " r 0 'Piping Sump/Trench Stnsor(s). Moielq 0-3 2 O Fill Sump Sensor(s). Model: , 1tvtechanical Line Leak Detector. Model: 0 Fill Sump Sensor(s). Model: 7Mechanical Line Leak Detector. Model: Fe' L t�� ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Modcl: Q Tank Dverfili / High -Level Sensor. Model: O Other (s eci ui rruttt t= and model in Section B on Pae 2 . O Other (specify c ui sent t and model in Section E on Pact 2), Tank ID: O In -Tank Gauging Probe. Model: Tank ID: O In -Tank Gauging Probe. Model: - O Annular Space or Vault Sensor. Model: G Annular Space or Vault Sensor. Model: ❑ Piping Sump /Trench Sensor(s). Model: O Piping Sump/ Trench Sensor(s). Modcl: ❑ Fill Sump Scnsor(s). Model: O Fill Sump Senors). Model: O Mechanical Linc Leak Detector. Model: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Lcak Detector. Model: O Electronic Linc Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ui ment t e and model in Section E on Page 2). O Other (s cif a ui ment typ c and model in Section E on Page 2). Dispenser ID:% Dispenser Containment Sensor(s). Model: 0 2-1 Dispenser ID: arDispemer Containment Sensor(s). Model. '71 320 `3d8 .'Shear Valvc(s). �Shcar Valve(s). s O Dispenser Containment Float(s) and Chain. O Vis nser Containmeni Float(s) and Chain s). Dispenser ID: E e Dispenser ID, f2' Dispenser ContainmentSensor(s). Model: a 02, Cl Dispense Containment Scnsor(s). Model: ,2( Shear Va)ve(s). O Sheat Valve(s)., ,, O Di5pcnscr Containment Float(s) and Chain s). O Dis cnser Containment F1oa s and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Shear Valve(s). ❑Disxnser Containrr:ent Float(s) and Chaises . O Dispenser Containment Floats and Chain(s). •If the facility contains more tanks or dispensers, copy this form.Inc ude 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 mooltoring equipment. For any equr ent capable of generating such reports, 1 have also attached a copy of the report; (check all float apply): O System set-up Alarhisto report Technician Name (print): I e G /4 Signature: „ c Certification No.: �7Iy2 D 8 y License. No.: _ b i/G Tesnag Company Name: Phone No.:�> 464-8 33 3 Site Address: s ' e Date of Testing/Servicing: /J/ Page 1 of 3 in F ' F �WF D 03/01 Monitoring System Certifcatiou JUN 2 4 2002 U il