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n / Vol _ N1 ISG SYSTEM C'E TIFICAU � For Use BY,4/1Jurisdictions 101hin 1he Slate ' of Califbrniu ZOO l is9alhority CilerlCheer 6. 7, f/ecrllh crndS.fe/v Code; Chcl/er /G, Division 3, Til/e 23, Ccli}orCot, ofRcruln liorrs 1,' 1—' ,T HEALTH This form must be used to document testing and servicing of monitoring equipment. A seDar c� itiNi6141 i1 ~ r rt must be prepared for each monitoring system control panel by the technician who performs the work. A c�py EtMfb/rt iiiLy 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 (late. A. General Information -r-) Facility Name: � 0(1)0'4 1 fV Nlr 1 . Bldg. No.: Site Address: W . 'c�`S-P r City: ca tA P Zip: '152-31 Facility Contact Person: w. el -1- (k1- Contact Phone No.: (2-01— Make/Model of Monitoring System: 6Ir.J?� S`fr S .� Date of Testing/Servicing: !8/,3(/6-7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: / Tank ID: FT�anD: ank Gauging Probe. Model: 0 (4 ❑ In -Tank Gauging Probe. Model•ular Space or Vault Sensor. Model: tt 'a ❑ Annular Space or Vault Sensor. Model: ng Sump / Trench Sensor(s). Model: U ❑ Piping Sump / Trench Sensor(s). Model: Sump Sensor(s). Model: U LS ❑ 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 -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 equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging 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: U Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ty a and model in Section E on PaLe 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 1D: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). me riciuty cuutams more tames or dispensers, copy nus rorm. include mtormation 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 equi ment capable of generating such reports, I have also attached a copy of the report; (check all that apply):S Alarm history report Technician Name (print):�� Signature: W=zr Certification No.:Zee -& 524 3,3 7 0T %�� License. No.: (377� 46th -/&-7 & Testing Company Name: 14_ ' oaf z Site Address: J p%1 1,„. � Date of Testing/Servicing: / t4 Page I of 3 Monitoring System Certification D. Results of Testing/Servicing 03/01