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r _ MO G SYSTEM CER C N For se ByAll.lurisdictions Within the State of California Authority Cited Chapter6 Z Health and Safety Code;Chapterl6.DwWon 3.71"de 23.California Code of Regulations t This foam must be used to document testing and servicing of monitocizig equipment.A ate certification or neoort must be prepgned r each monitoring�ystetn control panel by the technician who performs the work. A Dopy of this form mtsi be provided to the tank \ system ownet/opetatm: The ownedope ator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date, \\� Gencility es Information 0 5 y - Btdg.Noy - -- -Site dCity. a r -•z� — Tip: - - Facility ntact Person: Contact Phone No- Makc/Model of Monitoring System: 1—Z 3 Date of Testing/Servicing. B. Inventory of equipment Tested/Certified r thea boxes to Wicate qmcifx meat Tank ID: %�" Taadc ing Probe. Model: ►2 �-�c c II In-Tack Cog Probe. Medd s r SpaoeorVw*Seusor. Model: AnnularSpaoeorVaultSensor. Model L 6 Sunup/Trend Sensot(s). Model: Q•'Piping Sump/Trench Sensor(s). Model Flt Surd Seasor(sj. Model:�. ®Fitt Saagm Seasar(s). Model m odianical Line Leak Detector. Model: '1 Ptodtaaicd Etre Leak Ddactoc Model: �� ❑Eioctrvaic Line Leak Ddectoc Model: a EtOctmaic Line Leak Ddoctor. Mold: Q:y�'aamkOv+afill/Nigh-Le' K - Model: 'Z",3/S6 �/ �d-TankOvtafil[/ at�or. Model 2� G✓ lSb f�/ ❑Other( t and model in Section E on P 2). 0 Other( and model in Section E on Pa a 2). Tank ID- ark ID• L�J"L°y kln-Tank Gauging Probe. ModelVAO 000 TankGaueng Probe. Model `4 g,Annular Space or Vault Sensor. Model: v U AnnularSpace or Vault Sensor. Modd: - U QrR ping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: ❑ FU Sump Sutsoi(s). Model: ❑ Fall Sump Sensot(s). Model: �i..Mechauical Linc Leak Detector. Model- G 1> v .®"Mechanical Lice Leak Detector. Model: b EleCtnonic Line Leak Detector. Model: _ ❑ Electronic Line teak Detector. Model: AX-Tank Overfill/High . Modd:s I RTank Overfill I Ifiea evel Sensor. Model: Gv g/SI y t(Ckalisperiscr ther(s equipment an¢model in Section E on PaLe 2). ❑Other( ui t and in Section E on PaLe 2). enser ID: / Dispenser ID: 3 ispenser Containment s). Model: ❑Dispenser Containment Sensor(-). Modd: hear Vaive(s). tr Shear vaive(s). ' Containment Boat(s) Chain(s). D'a Containment Flo )and Chain(s). enser ID: 4 'Dispenser ID: ispenser Containment s). Model: ❑ DispenserContainmen s). Model: hear Valve(s). %t Shear Valve(s). is Containment Float(s)and Cliain(s). Containment Fl t(s and Chain(s). enser ID:_ �b'� Dispenser ID: z-7 ,7- 'ispenscrContainmentSensor(s) Model: ❑ DispeuserCoa ' Sensor(s). Model: hear Valve(s). Shear Valve(s). Containment Flog(s)and Chain(s). Containment Float(s)and Chain(s). `*If the facility contains more tanks or dispenses,copy this form. Include information for every tank and dispenser at the facility. G. Certification-1 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 tSv,9vffY that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any emi meati capable o ting such reports,I have also attached a copy of the�eck all that apply): System set-up eport Technician Name(print): G `rc.0—,^^ Signature: ry Certification No.: U /7 �''f License.No.: Testing Company Namc:T ®��U ec-oc�M�c�-� ® Phone NoABA-1 -) aw -7 o a 0 SiteAddress:252S 9tSoS Date of Testing/Servicing: ILI �d r:�� t .r3 uiat �luuit<u-iu;��>tru�Crt-titii:rtiun