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MONOORING SYSTEM CE T - ,ATI ON 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 report must be prepared for each monitoring 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 this form to the local agency regulating UST systems within 30 days of test date. A . General In nation Facility Name:/ ]yt , s �c, e r'�Q c s?� r c � Bldg. No.: Site Address: 35i Jif 0c: -C kr1AAl City:-G.t� r' Zip:- 9S,21/Cj Facility Contact Person: M4/21:y Contact Phone No.: ('W 7 ) Make/Model of Monitoring System: _CA h P t i l? Date of Testing/Servicing: 4 /_C/ 2_ B. inventory of Equipment Tested/Certified Check the appropriate boxei to Indicate specific equipment inspected/serviced: Tank ID: y i z. C Tank ID: ❑- In _Tank Gauging Probe. Motel: ❑ Tank Gauging Probe. Model: (J Annular Space or Vault Sensor. Model: 't P pular Space or Vault Sensor. Model: • �/ C .5 _ / ®" Piping Sump / Trench Sensor(s). Model: L19" F L� Piping Sump / Trench Sensor(s). Model: - O i ill Sump Sensor(s). Model: E3 Fill Sump Sensor(s). Yodel: j C N4echanical Linc Leak Detector, Model: krMechanical Line Leak Detector. Model: 1 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. \,Iodel: ❑ Other (s ecif equipment t and model in Section E on Pae 2). ❑ Other (sgecft equipment t and model in Section B on Page 2). Tank: ID: Tank ID: 0,1n -Tank Gauging Probe. Model: ❑ -Tank Gauging Probe. Model: nnular Space or Vault Sensor. Hovel: _G _A - fgrAhnular Space or Vault Sensor. .Liodel: —� _ Rr Piping Sump / Trench Sensor(s). Madel: 14A 41- - Wpiping Sump / Trench Sensor(s). Model: 4-A CY ❑'ll Sump Sensor(s). Model: ❑,Pill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Er Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment and model in Section E on Page 2). CI Oia Equi2ment type and model in Section E on Page 2). Dispenser ID: ) „J' 2- Dispenser ID: _ 5 ❑ )ispenser Containment Sensor(s). Model: ❑ Qispenser Containment Sensor(s). Siodel: �@ff Shear Vatve(s). ®''Shear Valve(s). �nser Containment Float(s) and Chain(s). O Dispenser Containment Float(s) and Chain(s). Dispenser ID: q Dispenser ID: 5, ❑�tspenser Containment Sensor(s). Model: O Pispenser Containment Sensor(s). Madel: (I Shear Valve(s). Cvl Shear Valve(s). ❑ Dis nser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Ch-;n(s). Dispenser IR Dispenser ID: ❑ Pispenser Containment Sensor(s). Madel:. Valve(s). ❑ Da'spenser Containment Sensor(s). Model: �+2 JnCur 41hear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). O Dispenser Containment Floats) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser a: the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in aetvrdance 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 ofgenerating such reports, I have also attached a copy of the report- �(/check ll that apply): CJ System set-up ® Ala tory r ort Technician Name (print): --� i/i.s Signature: ' Certification No.: License. No.: Testing Company Name: + Phone No.:(�_Ga' �y Site Address: 3o qs,5/3--Sc)"D"ateofTesLinz!S,-rvicin-:L�LOI/-L%2 Page i of 3 03/01 Monitoring System Certification