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r MONITORING SYSTEM CERTIFICATION For L/seBv,tllJurisdictions lfitlrin the state of California. fI utl;vri>i,Cued:Chapter 6.7.Health mrd 5afen 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 by the technician who performs the work- A copy of this form must be provided to the tank system owner/operato. The o loner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. l A. General Inform tion. q Facility Name: Site Address: LGL _ Bldg_No.:- _ City- t l Zip: '7 Facility Contact Person: ✓ /1t%7t L Contact Phone No.:{ � �7 --� Make/Modei of Monitoring/ stem y T r^J Date of TestingJServicing: _LR_/ q D& 11. laver,Uiy Of Equipilient ACJ LIE Wa.e tJllt'u Check thea ro riatt boxes to indicate C6!1 a ui meat inspected/serviced: J! / d+ - Tattle ID: t _ Tank ED: Z_ In-Tank Gauging Probe. Model- FJ-lt W in Gauging Probe- Model: _ e 9 Annular Space or Vault Sensor Model: u- ® Annular Space or Vault Sensor_ Model .0 Piping Sump/Trench Sensor(s). Moder: SE)-r}u . Iii-Piping Sump/Trench Sensor(,)_ Model: .. • 0–r-f-Sump Sensor(,)._ Model *Mechanical Line Leak Detector. Model. .y}A --�.'A- et Mechanical Line Leak Detector. Model `T}-d -,es 1-6 0 Electronic Line Leak Detector_ Model: 0 Electronic Line Leak Detector. Model_Tl' 0 Tank Overfill J Eiigh-Lcvel Sensor. Model: 0 Tank Overfill/High-Level Sensor.. Model: D Other( ci fiW ni and model is Section Eon Pa a 2)_ �.. er(s ecify ui menu t and model in Section Eon Paye 2}. Tani:fLl: D: � 0 In-Tank Gauging . Model: n-Tana Gauging Pro_e Model: 0 Annular Space or Vault Sensor_ Model. Q Annular Spacc or Vault Sensor. Model: _ 0 Piping Sump/Trench Sensor(,). Model: Q piping Sump/Trench Sensors). Model: 0.Fill SumpSensor(s). . Model: 0 Fill Sump Sensor(s)- Model: IQ Mechanical Line Leak Detector_ Model: Q Mechanical Line Leak;Detector. Model: O Electronic Line teak Detectar. Model: . D Electronic Line Leak Detector_ Model: - 0 Tank Overfill/tligh-Level Sensor. Moder 0 'Tank OverftEl i i ligh-level Sensor_ Model; O Other(s if of menu and model in Section E on Page 2)_ Other(s cif a ui men"t e and model in Section E on Paye 2)_ Dispenser ID: f�� Dispenser ID: _ �PC�h"n�Z F Dispenser Containment Sensor(,). Model: EDispenser Containment Senwr(s)- Model: Shear Valve(,)_ . , 3319 ��-nl Shear Valves)_ < fDjEe�TerConminment Floats)and Chain(s). Di Dispenser Containment Float(s)and Chain(s). riser ID: Dispenser ID: � Dispenser Con tainnxn Sef nso s M d 1 1— --` } _ Dispenser Containment Sensors}..� Moder. -� ehear�.✓aloe(,) L�' a3167 Gkrc hear Vaive(s). C7 Dis enser Containment Floats and Chain s). �S 3r? �` (}_ Di nser Containment Float(s)and Chain(s). D'upenser ID: Dispenser ID= Dispenser Containment Sensors}. Model: - 3 Dispenser Containment Sensor(s)- Model: - isShear Valve(s)-Con)_ 331 `7 DOa.. j-5 Q 3— 3 i r CCC�� 1�Q: Shear Valve(s)- Dis nser Containment Fioai{s)and Chain(,). �Dts nser Containment Float(s)and Chain(s). •If the facility contains more tanks or dispensers,copy tfmfs 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 Cori eel 8nd a.Pla.i pl5i°,hcrosioa:l:C Ia}r:;mt a�wC:it^r7AA==1;ti�Cneer For any•P�Ui TnC�t ca 2ble of o�,e- - ?- p r±erating such reports,I have also attached a copy of the re ore;(check all that apply): 1('ia�System set-up in history rep rt Technician Name(print); C�+ �� _ Signature. ,„ 'Certification No_: License_No.: Testing Cornpany Name:—all- G Phone No.:{�) `ll �33 l— JI` Site Address:_ .s3� L[:T tCrGw i'Y Lce �SZc3 S Date of festing/Servicing: to /,;LwLT i� Page I of 3 t)3.OS Monitoring System Certification Td 2frE9 T 9t,60Z ou I saojoe,a4uo0 n I a4 t I3 dal t TO 90 EZ 400