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• MOOFORING SYSTEM CER CA.TIN 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, CalifornianCode dations 0 This form must be used to document testing and servicing of monitoring equipment. A Q e4` . � CJ (rl re ort 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 10 e ting UST systems within 30 days of test date. Ut 761 A. General Information PERVIO ENT HEALTH Facility Name: ��a rnJ MIT/S gl No.: Site Address: f l V ,Sd `` City: Zip: Facility Contact Person: pp Contact Phone No.: z( O°1 ) �i Z D 1 K Make/Model of Monitoring System: Outer. "or -M S 3 3'0 Date of Testing/Servicing: to ! «/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: # I Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: O 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: 1 O Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 1O� electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). O Other(specify equipment type and model in Section E on Page 2). Tank ID: A'3 L c.� TankID: Af Y X�U 7~ ❑ In-Tank Gauging Probe. Model: 1_l In-Tank Gauging Probe. Model: U Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: « Electronic Line Leak Detector. Model: P/ty ❑ Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: Cl Other(specify equipment type and model in Section E on Page 2). Cl Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: El 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: ❑ Dispenser Containment Sensor(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: O Dispenser Containment Sensor(s). Model: Q Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser 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): ❑ Siup U Alar history report Technician Name(print): tCr'°�A yn rA r-,r Gf Signature: ertification No.: L l (I.- � License.No.: Testing Company Name: {�� asw' PhoneNo.:� q 2�� } S l �S S Site Address: 1101 �, V-vt +N Sr" /vlA J+C441 Date of Testing/Servicing: 6 / !erl "L Page I of 3 03/01