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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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 ystem 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 Infor ation Facility Name: C., r'P a &n Pr Bldg. No.: Site Address: / City: e Zi Facility Contact Person: Contact Phone No.: 0 J Make/Model of Monitoring System: ig& 4 o A. Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate specitic equipment inspected/serviced: Tank ID: / In -Tank Gauging Probe. Model: Tank ID: i ❑ In -Tank Gauging Probe. Model: C #1 if Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 1p�Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: If ill 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: 0 Tank Overfill / High -Levet Sensor. Model: ❑ Other i ui ment type and model in Section E on Page 2).u ❑ Other i i mentype and model in Section E on Page 2)_ Tank [D: Tank [D: ❑ 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: 10 0 Fill Sump Sensor(s). Model: 0 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 -Levet Sensor. Model: ❑ Other s eci ui ment ty22 and model in Section E on Paae 2). Other s eci ui ment type and model in Section E on Pae 2 . ispenser ID: Dispenser ID: Dispenser Con ainment Sensor(s). Model: �, i L ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chains . ❑ Dis nser Containment Floats and Chain(s). Dispenser [D: ❑ Dispenser Containment Sensor(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shcar Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chains . *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility.