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f N NG SYSTEM CE TIF � For U,e Bv.-tll Jzrrisdiclions hd•ilhin the,Stale of Califor•rzia Azrihorily Cited: Chapler 6.7, Health curd Sgfety Code; Chapler/G, Division 3, Tille 23, Cczlifornicr Code of Re illation This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring 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 the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: _ Y A Bldg.No.: Site Address: 3.3® City: ",,�---�-Q� T®tom Zip: Facility Contact Person: Contact Phone No.:( ) Make/Model of Monitoring System: �� — Date of Testing/Servicing: —T—/l o B. Inventory of Equipment Tested/Certified Check the auproyriate boxes to indicate s eeific a ui Ment ins ected/seryiced: Ta D: �"� pC•-(- Tanl ID: Tank Gauging Probe. Model: 'R111-Tank Gauging Probe. Model: 6t nular Space or Vault Sensor. Model: Z® fd' ular Space or Vault Sensor. Model: p Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: QA$ ❑ F' I Sump Sensor(s). Model: ❑ F'll Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: S-P- Mechanical Line Leak Detector. Model:_GIC-/0 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty e and model in Section E on PaLe 2). ❑ Other(s ecif equipment t e and model in Section E on PaLe 2). Tan ID: 9 1 a--r Tank ID: In-Tank Gauging Probe. Model: AfA&/ ❑ In-Tank Gauging Probe. Model: ❑ ular Space or Vault Sensor. Model:— ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: O$ ❑ Piping Sump/Trench Sensor(s). Model: ❑ FAI Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: y ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify e ui Ment t e and model in Section E on Pa a 2). ❑ Other(s eci a ui Ment ty e and 5Ch'.n E on Pae 2). Dispenser ID: ' t Z- Dispenser ID: "•'r i-•a ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). S ear Valve(s). W"Shear Valve(s). is enser Containment Float(s)and Chain(s). .0-Dispenser Containment Float(s)and Dispenser ID: t Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). � iear Valve(s). ❑ Shear Valve(s). Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Dispenser ID: Ip Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ DispenserContainmentSensor(s).,0'�hear Valve(s)• ❑ Shear Valve(s)is enser Containment Floats)and Chain(s). ❑ Dis enseContainment Floats)and *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 equ' ent. For any equ' ent capable of generating such reports,I have also attar d a copy, f he report;(check a//that appiy): Syste e- Alarm history report Technician Name(print): ( (p/1/ylp Signature: Certification No.: l($3 �---� License.No.: 0 Testing Company Name: — [ Phone No.:(Z27 )7YA p /( Z.— Site Address: 33C> P, . `a r Date of Testing/Servicing: $//d /07- P,rge I,tW1 03/01 Monitoring System Certification I). Results of Testing/Servicing