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Sep 28 02 02:37p p.3 MONITORING SYSTEM C:ERTi l..A.TION r For Use By All Jurisdictions Within the State of Calafomia authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be for each nmnitorime system pane control l by the technician who performs the work A copy of this form must be provided to tthe tank he ttants 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 Ortf Ohl' Facility Name: Bldg. No. Site Address- Angn /K1 City- .e zip:&,-,�/O Facility Contact Person: i /% Contact Phone No.: ( — )_ g3�'�_.!` `4 Make/Model of Monitoring System: d�O of �! Date of Testing/Servicing: 45 /d B. Inventory of Equipment Tested/Certified Check the annrenriate Loxes to Indicate specific egniptaent�tet T k ID: 1111=4 t +-Tank Gauging Prob a/Arnular.Space or Vault Sensor. Cit Piping Sump / Trench Sensor(s). ❑ Flu Sump Sensor(s). d Mechanical Line Leak Detector. ❑ ectronic Line Leak Detector. Cr Tank Overfill / High -Level Sensor. ❑ Other (snecifv eouirnnent tvue and Model: ,l5/j Model: Model: Model: Model: Model: Model:22K �Z- todel in Section E on Page 2). T k ID: ('A-Tank Gauging Pro e. alar Space or Vault Sensor. Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). eehanical Line Leak Detector. ❑ Electronic Line Lease Detector. Q Tank Overf III / High-level Sensor. Model: W Model: Model: Model: Model: `p�O Model: Model• iodel in Section E on Pace 2). Tank ID: Tank ID: ®pispenser Containtncnt Sensor(s� Model: O In -Tank Ganging Probe. Model: ❑ In -Tank Gauging Probe. Model• ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: . ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑• Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical. Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Leve! Sensor. Model: ❑ Tank Overfill/ High -Level Sensor. Model: ❑ Other (specify enuiomcnt tvpe and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Palo 2). Dispenw ID: Dispenser ID. - 0 D:❑ Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). / ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Contz6nment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this foot. Include information for every and dispenser at the 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'�chedkiists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment For any 4qui t capable of generating such reports, I have also attached a copy of the check all tlta% Yy): ® System set -tip Gory report Technician Name (print):dox &C Sigttature• +""rte Certification No.: :57.2 Z License.No.• Testing Company Name: jZdl % Phone No.. } � Site Address: zirl i V, je-yo r -EA/ r, y AX /Z7 f- Date of Testing/ServicbW. Page I of 3 0"1 Monitoring System Certffication hspenser Conment Smsor(s). Model: 0-bear ®pispenser Containtncnt Sensor(s� Model: Valve(s�tain {3 Shear Valve(s). v ❑ Dis enser Containment Floats) and Chains . ❑ Dispenser Containment FloLt(q and Chains . D enser ID: D" eraser ID: ispenscr Containment Sensor(s). Model: [,Dispenser Containment Sensor(s). Model- 15Shear Valve(s). (4 Shear Valve(s). ❑ Dispenser Containment Floods) and Cbain(s). ❑ Dispenser Contaftu telt Float(s) and Chain(s)- Dispenw ID: Dispenser ID. - 0 D:❑ Dispenser Containment Sensor(s). Model• ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). / ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Contz6nment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this foot. Include information for every and dispenser at the 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'�chedkiists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment For any 4qui t capable of generating such reports, I have also attached a copy of the check all tlta% Yy): ® System set -tip Gory report Technician Name (print):dox &C Sigttature• +""rte Certification No.: :57.2 Z License.No.• Testing Company Name: jZdl % Phone No.. } � Site Address: zirl i V, je-yo r -EA/ r, y AX /Z7 f- Date of Testing/ServicbW. Page I of 3 0"1 Monitoring System Certffication