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P 4 MONITO G SYSTEM CERD MATION For Use By All Jurisdictions Within the State of California w Authority Cited.• Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, 77tle 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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 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. Instructions are printed on the back of this page. A. General Information Facility Name: a,igLaj!t/2q Bldg.No.: 1,4 Site Address: City: c q Zip: 22L—)j(=. Facility Contact Person: ,k ,c,,A6h Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: 01 In-Tank Gauging Probe Model: 9P In Tank Gauging Probe. Model: PQ Annular Space or Vault Sensor. Model: 40Y Annular Space or Vault Sensor. Model: 4 0 Piping Sump/Trench Sensor(s). Model: 20 Piping Sump/Trench Sensor(s). . Model: LOQ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: (=kltf 4 Mechanical Line Leak Detector. Model: !d-A--rX3 ❑ Electfdiiic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: P Tank Overfill/High-Level Sensor. Model:_ C_-QjqkY,, 0 Tank Overfill/High-Level Sensor. Model: �W4/oc, ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: W Shear Valve(s). JA Shear Valve(s). 9k Dispenser Containment Float(s)and Chain(s). ,W Dispenser Containment Float(s)and Chain(s). Cl Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 91,/ Tank ID: �1 In-Tank Gauging Probe. Model: Z ❑ In-Tank Gauging Probe. Model: l Annular Space or Vault Sensor. Model: t/( ❑ Annular Space or Vault Sensor. Model: ,Q Piping Sump/Trench Sensor(s). Model: ZoR" ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 2) Mechanical Line Leak Detector. Model: J�,(l� ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: J] Tank Overfill/High-Level Sensor. Model: ORJ`1/OL ❑ Tank Overfill/High-Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I Shear Valve(s). ❑ Shear Valve(s). W Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). 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 Site Plan showing the layout of monitoring equipment. For any equipment c::p:1h1.e of a cola. of the ihar u!,t,lrl: ``N"�icnt set-111) rc Technician Name(print): Cert./Lic.No.: Sienature: d Testing Company Name: �y,�-�(y;r� a�� Phone No.: