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MONITORING SYSTEMCERTIFICATION 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 rep be rt must be to he tank for ea h monitorin s stem control anel by the technician who performs the work A copy of this forte must be provided to the tanx system ownerloperator• The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General inform tion Bldg. No.: Facility Name;city: z� r zip: j ,�'+ �(• a Site Address:-_ l r Contact Phone No.: (—) Facility Contact Person: Date of Testing/Servicing: =c Make/Model of Monitoring System' — — '-'— B. Inventory of Equipment Tested/Certiried ..:. _._t i emcted/servlced: _ Tank ID: 0 In -Tank Gauging Probe. U Annular Space or Vault Sensor. ❑ pilling Sump / Trench Sensor(s). Cl Fill Sump Sensor(s). 0 Mechanical Line Leak Detector. L3 Electronic Line Leak Detector - Ll l Tank Overfill / High -Level Sensor. Ll Other (speci e4un merit t e and TankiD• 7- 0 In -Tank Gauging Probe. • Annular Space or Vault Sensor. • Piping Sump/ Trench Sensor(s). ❑ Fill Sump Sensor(s). Q Mechanical Line Leak Detector. L) Electronic Line Leak Detector. LI Tank Overrtll / High -Level Sensor Model:— Model:u- Model: Model: Model: Model: -- Model: Model: Model: Model: Model: Model: Model: Dispenser ID: Model: Q Dispenser Containment Sensor(s). u -Shear Valve(s). _[l Dispenser Containment Floats) and Chain s Dispenser ID: u Model: Containmen Scnsor(s). U'Shear valve(s). ❑ Dispenser Containment Floa s) and Chain(: Dispenser ID: _ 5 p'Disgeuser Containment SensoI(s). Model: QShear Valve(s). on Tank ID, U In -Tank Gauging Probe. odei C3 Annular Space or Vault Sensor. Model: . L3 Piping Sump / Trench Sensor(s). j3 Fill Sump Sensor(s). Model:. 0 Mechanical Line Leak Detector. Model,, 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: L] Other (sped' equipment type and modeller Tank ID: fu L) 1n -Tank Gauging Probe. 1 lodel: 0 Annular Space or vault Sensor. mom: L] Piping Sump/ Trench Sensor(s). E3 Fill SSensor(s). ump Model: Ll Mechanical Line Leak Detector. Model: 0Electronic Line Leak Detector. ❑ Tank Overfill / High - e Sensor. Model: .-. ,..._ __ ,mF. o,,,,;, me_„ t tvne and model in Dispenser ID: U -Dispenser Containment Sensor(s). Model: U -Shear Valve(s). 0 Disocnser Containment Floats) and Chain( Dispenser ID: 0 Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). _ n....so;. nt Flnat(s) and Cham(; Dispenser ID: E3 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). fo Include information for every tank and dispenser at the Ell .y{ the facility contains more tanks or dispensers, copy un, manufacturers, checklists) necessary to verify that this information is C. Certification - I certify that the equipment rdenttlied in this document was tnspected/serviced in accordance with the manufacturers guidelines. Attached to this Certification is information t meat F'ar any equipment capable of generating such reports, I have also correct and a Plot Plan showing the layout of monitoring System set -tap ®AFarffi Story` rrg rt attached a copy of the report (check all that apply): Y ( /n �---- Signature: "x L t� r 'tf u r �� .�. � Z Technician Name (print): -- r �� . l 05 t. 7 i License. No.: Certification No.: } Phone No.: � gy Testing Company Name: l� ` �� /� pr� f •:� Date of Testing/Servicing: Site Addrw: ` `r 03/01 Page I of 3 Monitoring System Certification