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MON RDD SYSTEM CERTIFAT1111,,PECE- WlEDD For Cu 8v 111,Juris(flclions fl'ilhm elle Siwc of Cali/urnicr .4ulhoriov Cited: Chopler 6.7, 1-leallh crud Suk0,'C0(1(!,' ChaPer 16, Division 3, Ti/le 23, California CoApl?&4,1,/ZD�8 This f01-111 111LIst be used to dOCL]Illellt testing and servicin., of nionitoriiiz, equipment. A separate cerp%�[ Ni-1911MEALTH, prepared for each monitoring system control panel by the technician who performs the work. A copy of this PERWlr� CEGd to the tank sys to owner/operator. The owner/operator 111LISt Submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Intot' ,rVa ion Facility Name: _(_Vj)'Ncj( Bldg.No.: Site Address: /Fol _V. 'r—/ OVOCIP 0 S+ City: Zi 'fzq'6 Facility Contact Person: M 0 Z_ Contact Phone No.: Make/Model of Monitoring System: r1r, gs —_?oq , Date of Testing/Servicing- B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecilic equipment i uspected/sery iced: T. k Ill 0 CA- Tank ID: In-Taill,Gauging Probe. Model: -.10 in-Tank Gauging Probe. Mod Annular Space or Vault Sensor. Model: Mod'e��. _5�ze) - LJ Annular Space or Vault Sensor. ;_11"Piping Sump/Trench Sensor(s). Model: Z_0.k 21"Piping Sump/Trench Sensor(s). Model: ��F Sump Sensor(s). Model: C) Fill Sump Sensor(s). Model: FLI Fill Sui e4�v ,FerMechanical Line Leak Detector. Model: -!;'—)P 111CO Mechanical Line Leak Detector. Model- -onic Line Leak Detector. Model: J Electronic Line Leak Detector. 1 0 Electronic l AModel.�r e-00 L3 Tank Overfill/High-Level Sensor. Model: Ll Tank Overfill/High-Level Sensor. McModel:( e— Ll Other(specify equiElment type and model in Section El Other if (specy eqUienient type and model in Se I Ltion E on Page 2). Tank ID: Tank ID: LJ In-Tank Gauging Probe. Model: U In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: 0 Piping SUll/Trench Sensor(s). Model: El Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: x 13 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 4 N 13 Mechanical Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: LJ Electronic Line Leak Detector. Model:*�� E3 Tank Overfill/High-Level Sensor. Model: Ll Tank Overfill/High-Level Sell Model: L3 Other(s ecify e Lill proent ty e and model in Section E on Page—2). ❑ Other(s 'fLjeuipnient type and model in Section E on P Dlpenser ID: Dispenser ID: fof Dispenser Containment Sensor(s). Model: 01 Dispenser Containment Sensor(s). Model: XShear Valve(s). aShear Valve(s). LL3 Dispenser Containment Float(s)and Chain(s). Ll Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: C3 Dispenser Containment Sensor(s). Model: LJ Dispenser Containment Sensor(s). Model: LJ Shear Valve(s). LJ Shear Valve(s). Q Dimajaf2212inrnent Float(s)and Chairl 13 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: L3 Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: (3 Shear Valve(s). Q Shear Valve(s). 013liseenser Containment Float(s)and Chairl Ll Dispenser Containment Floats)and Chain(s), *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility.—' SAN V0,,ko-V C. Certification - I certify that the equipment identified in this document was inspected/serviced d/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 app&): LJ System set-up 13 Alarm history report Technician Name(print): k Signature: Zee W Certification No.: B License.No.:67TI # — I-— — Testing Company Name: P 11 o n e No.:02o Site Address: Date of esting/Servicing: Page I of 03101 Monitor.ing S I ystern Certification A Results of Testina/Servicino, C,®.