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MONITORING SYSTEM CERTIFICATION AM For Use By All Jurisdictions Within the State lifornia Authority Cited: Chapte Health and Safety Code; Chapter 16, Division We 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: STOC KI`O) A QST Bldg.No.: Site Address: ZM3 Sq'i mScQ j?bCity: f,-Trac k-TZSQ Zip: 9 S 2,06 Facility Contact Person: S t Ct�tJ tit C>41 Contact Phone No.: (Z G83 - 533/ Make/Model of Monitoring System: E Btu...) p 01 i al S"K t t j 2 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific a ui ment Ins ected/serviced: Tank ID:LJ K A S`r Tank ID: L 2 0 In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: t i!S Annular Space or Vault Sensor. Model: U LS Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). 'Model: L)L5Fill 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-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s if Squipmen t and model in Section E on Pae 2). ❑ Other(SeEi[y Sguipment t and model in Section E on Page 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specia ui ment t)TSand model in Section E on Pa a 2). ❑ Other(specify equipment t and model in Section E on P e 2). Dispenser ID:-T AMS i ZN Sump Dispenser ID: Q CCl_ U D f— ,lam Dispenser Containment Sensor(s). Model: u L S Dispenser Containment Sensor(s). Model: U LS ❑ Shear Valve(s). Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser 1D: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ElDispEnser Containment Float(s)and Chain(s). ❑ Dis user 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 e i went c able of generating such reports,I have also attached a copy of the re}�cwt_ (check all tha(epply): ®System set-up a istory report Technician Name(print): IJ f wt_"ta Signature:I Certification No.: License.No.: S71 2 If LV_ Testing Company Name: 'T'A"V-—1 Tac- Phone No.: ( �o f `�- ►_ 00-1-7Site Address: -77Y-f S a -+�. t.ct + AVC d 8 �Ftu�urA CA, 4j7007.% Date of Testing/Servicing: Monitoring System Certification Page 1 of 3 03/01 t