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g ONISYSTEM CERTIF ' NTION F s . e By All Jurisdictions Within the State of Ca is ` 'Authority Cited: Chapter 67, 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 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. A. General Information Facility Name: � lXAZY $2 /__.-� Bldg. No.: �7 Site Address: g z �i� / City: �,�� { e Zip: 2 _3 3 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate ecic ui ment ' ted/serviced: Tank ID: Tank ID: y I w ❑ In -Tank Gauging Orobe. Model: 2r? �? ❑ In -Tank Gauging Probe. Model: s�- -%.< �? ❑ Annular Space or Vault Sensor. Model: !!* 9411901' �Y ❑ Annular Space or Vault Sensor. Model: <25 ❑ Piping Sump / Trench Sensor(s). Model: 1-01 ❑ Piping Sump / Trench Sensor(s). Model: o _ ❑ Fill Sump Sensor(s). Model: A ' ❑ Fill Sump Sensor(s). Model: �g� ❑ Mechanical Line Leak Detector. Model: LIXX ❑ Mechanical Line Leak Detector. Model: Z=x V Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ci a ui ment and model in Section E on Pae 2 . ❑ Other (s i e ui ment and model in Section E on Tank ID: 6e4 4 Tank ID: ❑ In -Tank Gaug' g Probe.. Model: — ❑ In -Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: e. -3 90 ifL.ef- ❑ 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: 15� 1 "l 5/ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 7'0: Tank Overfill / high -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other �spEitK e ui ment type and model in Section E on Pae 2). E3 Other (s i e ui ment and model in Section E on Pae 2). Dispenser ID: a -z---- Dispenser ID: ---- 1 Q Dispenser Containment Sensor(s). Model: `�C 13 -Dispenser Containment Sensor(s). Model: ' r Uj Shear Valve(s). Valve(s). ❑ Dis ' ,nser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: U• E')ispenser Containment"Sensor(s). Model: Z Q Hispenser Containment Sensor(s). Model: r U Shear Valve(s). @-Shear Valve(s). ❑ Dispenser Containment Float s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [d'6spenser Containment Sensor(s). Model: °?- gip' ❑ Dispenser Containment Sensor(s). Model: shear Valve(s). ❑ Shear Valve(s). (313ispenser Containment Float(s) and Chain(s). ❑ 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 that apply): ys em set-up EYA' la history port Technician.Name (print): $0,217 R1 4, r Signature: Certification No.: C�),S - C9 r License. No.: Testing Company Name: 11ei V _t'l , r Phone No.:C Site Address: Date of Testing/Servicing:�� Page 1 of 3 03/01 Monitoring System Certification Post -it® Fax Note 7671 Date -7 pages® r From t V Co./Dept. Co. Phone # Phone # Fax # Fax #