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MONITfWJNG SYSTEM CERTINTION a For1W By All Jurisdictions Within the State of Cali,*a 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 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: !'4' j S Y." y/ Bldg. No.: Site Address: e1el�/�//% s .s -,/s City: —!2 Zip:. 2 —33e4 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 specific equipment inspected/serviced: Tank ID: !" Date , c� -rj Tank ID: 11 t z 1 To T'Y)L. _ l I � 0 -fn --Tank Gauginj Probe. Model: Z 96- C3 In -Tank Gauging Probe. Model:9 "nular Space or Vault Sensor. Model: c0_ q)-& ❑ Annular Space or Vault Sensor. Model: /) , _a 3e ^' ev _-<r 54 tping Sump / Trench Sensor(s). Model: 4` c 9 43 Ze-- ❑ Piping Sump / Trench Sensor(s). Model: 6,4 v 90 fe --Z-4 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: (Mechanical Line Leak Detector. Model: Ft -41l_%L ❑ Mechanical Line Leak Detector. Model: FrAr ,. V-A m L1 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment and model in Section E on Pae 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Tank ID: ' — Tank ID• ❑ In -Tank Gaug g Probe. Model: A1*. X SG - a 9 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ) 9gJ4C -• Vx—' ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: V ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: W� Z, � SI'I� �/� � ❑ 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 and model in Section E on Pae 2). ❑ Other (specify equipment and model in Section E on Pae 2). Dispenser ID:�- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 7 ❑ Dispenser Containment S nsor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: (/ Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: �T ❑ Dispenser Containment ensor(s). Model: d ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Disperser ID: _ _ Dispenser ID: - ❑ Dispenser Containment Senso (s). Model: 7-'c; gn �' Hrspenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis nser 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 : U*stem set-up EI-MaryWhistory a ort j Technician,Name (print): P' cR .1 %r'i`m �' ti Signature: Certification No.: /: e 6- -- G" -5 - G 2- °) ef) License. No.: Testing Company Name: Lll(�A :)e n -e _.j. "-7,e : Phone No.:() Site Address: Page 1 a Monitoring System Certification Post -it® Fax Note 7671 Date , c� -rj pages"' 4- To T'Y)L. _ l I � From v Co./Dept. Co. Phone # Phone # Fax # 53 3- a (, 5v ii Fax # 4-G&