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MOIW6RING SYSTEM CER ICATION 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 system control erforms the work. A copy of this form must be provided to the tank system owner/operator. The owner/opsZ f=i i y of this form to the local agency regulating UST systems within 30 days of test date. A. General Information� AUG .0 8 ZOOZ -4*t?('9'/ Facility Name: t�lr,t rxl AUH Bldg.No.: Site Address: tr/o Sd a E 1I�SERVICE City: /11&,-,f>_ Zip: Facility Contact Person: n Contact Phone No.: Z( O � ) 6 Z S D Make//Model of Monitoring System: t� - -�- -t-t s 5'� Date of Testing/Servicing: to / t q1 2- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: # 1 J nrr.v.L_ Tank ID: 417- 13 17-❑ In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: ;i ❑ Piring Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _^M _ 0 F.11 Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: _ ❑ Meebanical Line Leak Detector. Model: Electronic Line Leak Detector. Model:_—pl t � Z !''�iectronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: q__ ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in S::ction E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 3 Llwo Tank ID:_ A i 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model:�t 0 �EIectronic Line Leak Detector. Model: P 1l ❑ Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: 0 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: ' O Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: �• O Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: w ❑ Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). 0 Shear Valve(s). ODispenser Containment Float(s)and Chain(s). O 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): 0 Systems t-pup 0 Alarm history report ` ^ Technician Name(print): /C;-,1A 1c, t 4, Gl Signature: Certification No.: L I OL License.No.: Testing Company Name: (nim-rrL du a,• Phone No.:( R ZS^ ) .SSI ?SS- 5— Site SS- 5— Site Address:_ 1101 r- 14 A V+C4- Date of Testing/Servicing: 6 i Page i of 03/01