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DEC-26-2007 13.25 Service Station Systems 408 938 8888 P.02 MONITANG SYSTEM CE TIFICA N For Use'By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code,Chapter 16,.Division 1, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certifacatiot ar M2011 trust be spared for each monitoring_cystern ggntroi 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 Informati n Bldg.No.: Facility Name: Site Address: D City. `t/1y Zip;_ -- Facility Contact Person; lei _ _ Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Servicing; B. Inventory of Equipment Tested/Certiffed Check the appropriato boxes to indicate ecific walpment in ected/serviced: TanklD; Ta ID: G iT -Tank Gauging Probe. Model: '` 1f/ " t V Tank Gauging Probe. Model: Haler Space or Vault Sensor. Modcl, �Z ular Space or Vault Sensor. Model: Cri Piping Sump/Trench Sensor(s). Model: r Ldp Piping Sump/Treztell Sensor(s). Model: ® Fin Sump sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: Q Mechanical Line Lcak Detector. Model: ❑ Mechanical Line Leak Detector. Modal: Q Electronic Line Leak Detector. Model: e Q Electronic Line Leak Detector. Model: , 0 Tank Overfill/High-Level Sensor. Model ❑ Tank Overfill/High.Lcvei Sensor. Model: ❑ Other s ec ui ent and model in Section E on Page 2). ❑ Other eci i spent a and model in Scction E on Pa e 1 . Tank YY?: Fi Tank ID: - -- ® ❑ [n-Tank Gauging Probe. Madel: Gauging;Probe. Model: � gW,,,,hk lar Space or Vault Sensor. Model: Q Annular Spacc or Vault Scnsor. Model:Sump t Trench Scnsor(s). Model: ❑ Piping Sump I Trencth Sensor(s). Model: ® Fill Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model U Mechanical Line Leak Detector. Model: ❑ Mechanical Linc Leak Detector. Model, ❑ Electronic lane Leak Detector. Model; - ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/Higb-Level Sensor. Model ❑ Tank Overfill/High-hovel Sensor. odelModis ❑ Other(s e' e i trent a and model in Section E on a e 2 . ❑ Other(s ci a tai menu and model in Section E on Page 2 . Dispenser ED: Dispenser YD: • Dispenser Containment Senso!and t: ❑ Dispenser Containment Sensor(s). ode ❑ Shear Valve(s). [a Shear Valve($). ❑ Di Baser Containment Floathain($. ❑ Dis neer Contaitament Floa and Chain(s). DDispenser ID: Dispenser ID: Q Dispenser Conrainrncut Sensar(s). Model: ❑ Dispenser Containment Sensors) d : ❑ Shear Valve(s). 7 ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chains . ❑ Di eraser Containment Float(s) Chains . Dispenser M; Dispenser ID; O Dispenser Containment Seflsor(s). Model: ❑ Dispenser Containment Cl Model: .— Cl Shear Valve(s). ❑ Shear Valve($). ❑Dis ser Contaittmcnt Floats and Chain s). 13Di neer Containtaent Floe s and Chains . •1f the facility contains more finks or dispensers,copy this form. Include information for every tank aid 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 Pian showing the layout of monitoring equipment. or any egninanent capable of gen .ting such reports,Y have also att.ehcd a e e sport (check al!that apply): Ste set-up rm Technician Name(print): r/�R —@, SignaturQ?' Certification No,: f 6 Loewe,N . t Testing Company Name: Phone No.. D Site Address; Date of Testing/Se vicing: Page 1 of 03/OB Monitoring System Certification D. Results of Testing/Servicing