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O P g ®RING SYSTEM ��ATION � hqI`lU.ve Big.-1l/Jurisdictions 1171hira Irua t Authar•i1v 01etk C'halwer 6.7, Health and S'ufc lv('ode, C'hap/er/G, Division 3, Tille 23, C'aliijrrrnia C,oele of Re g ulalions This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorin�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 Ibis form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: fo� `�G I 1 Bldg.No.: Site Address: QQQ ty'1 I C,nne"A n 1 I -35 City: Zip: Facility Contact Person: SG I Contact Phone No.:( ) Make/Model of Monitoring System: Le'a k— P l Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the avxro riate boxes to indicatespecific a ui ment inspected/serviced:. Tank ID: 'DI 'SC) Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: &Annular Space or Vault Sensor. Model: LALS 'Annular Space or Vault Sensor. Model: LG C 'Piping Sump/Trench Sensor(s). Model: L Q LS 4 Piping Sump/Trench Sensor(s). Model: c.L S ❑ 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(s cif equipment ty a and model in Section E on Pa a 2). ❑ Other(specify equipment t e and model in Section E on Pa a 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(sEeciLy a ui ment!Xpe and model in Section E on Page 2). ❑ Other(seecifZ a ui ment!Zpe and model in Section E on Pa a 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser 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 attach d a copy of the report;(check all that npplv): ❑ Syst �t—u, OjAlar�m1ti5ta " ry eport TechnicianName(print): Signature: Certification No.: License.No.: `�U Testing Company Name: 40 -DA �p S� Phone No.:( oq � 2�4-C�l Site Address: Date of Testing/Servicing: � Monitoring System Certification Page 1 ofd 03/01 D. Results of Testing/Servicing