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t MON14kRINGSYSTEM CE 'TIN 'TI N j U L '13 L'L For Use 6y All.lurisclictions 6I''ithin the ,State of Ccrlifbrnia Authoritt C'itecl: Chapter 6,7. Health and Safety Cocle; Chapter 16, Division 3, Title 23, Calif�r min Code cJ'Re,��tilntions This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorinystem 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 sycf6ins within 30 days of test date. A. General Information m �5 Facility Name: Bldg.Q� H Bldg.No.: Site Address: �✓a � lr/C- A t/+� City: �ToL1t-�o•� Zip:—fto!7 Facility Contact Person: S'TE✓e Contact Phone No.:( ) T JX- j Make/Model of Monitoring System: 1(( OoC rr 11CZ> 3�® Date of Testing/Servicing: 916107- B. 9/ 6 / O7B. Inventory of Equipment Tested/Certified Check the aperoeriate boxes to indicates ecific equipment ins ected/serviced: Tank ID:2`4 ®f;7 Tank ID: 1 pL 1W In-Tank Gauging Probe. Model: Cit In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 117-0 Annular Space or Vault Sensor. Model: 7. Piping Sump/Trench Sensor(s). Model: 05 Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 15L Mechanical Line Leak Detector. Model: A 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(specify equipment ty a and model in Section E on Pa a 2). ❑ Other(specify e ui ment t e and model in Section E on Pae 2). Tank ID: pC-Tank ID: In-Tank Gauging Probe. Model: A61 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Uo ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model Z®5 A Piping Sump/Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ift Mechanical Line Leak Detector. Model: J4 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(specifZ a ui ment type and model in Section E on PaLe 2). ❑ Other(speciLy equiement!yee and model in Section E on Page 2). Dispenser ID: I I- -- Dispenser 1D; It "I- 1 Z ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment ensor(s). Model: Shear Valve(s). Aff Shear Valve(s). Dispenser Containment Float(s)and Chain(s). A Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3,S at- '+- Dispenser ID:_ 1 3. 1� 4 i D115 001 ® Dispenser Containment Sensor(s). Model- ❑ Dispenser Containment tensor(s). Model: AShear Valve(s). Shear Valve(s). gl Dispenser Containment Float(s)and Chain(s). MWis enser Containment Float(s)and Chain(s). Dispenser ID: 7,9 Jnr- 5, 10 Dispenser ID:- 15- It, D ire C P -°f Dispenser Contai rnent Sensor(s). Model: ❑ Dispenser( tainment 5nsor(s). Model: Shear Valve(s). IkShear Valve(s). Dis enser Containment Float(s)and Chain(s). K 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 reports,I have also attached a copy of the report;(check all Mai apply): A S ste se -u E.Alarm history report Technician Name(print): ; n Signature: Certification No.: License.No.: � Testing Company Name: or _ a - Phone No.:( _) Site Address: Date of Testing/Servicing: V1.-/47 r� Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing