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MONITO&G SYSTEM C(`t�j nn r TI NT l.L' it CATI®1V For Use By All Jurisdictions Within Me State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regutadons This form must be used to document tasting and servicing of monitoring equipment. A Warate certification or report must be pncpgMd for each monitoring system control panel by the technician who performs the work. A dopy of this form must be provided to the tank system ownedoperator. The ownedopetator must submit a copyof this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: 03, 1 Y Bldg. No.: ' Site Address:ty� ��n �d/i✓ /�2.4c. Ci Zip: Facility Contact Person: - Contact Phone No.: C� Make/Model of Monitoring System: re-" C Date of Testing/Servicing. B. Inventory of Equipment Tested/Certified Testing J Check thea rn riate boxes to indicate• re meatservi ced " Tank ID: ct'? Tank ID: ❑ In -Tank Gauging Probe- Model: VA01,4, ❑ In -Tank Gauging Probe. Model: ❑ Annular space or vault sensor. Model: V 2 d 9 ❑ Annular space or Vault Sensor. Model: LI/1- ye�! 9 ❑ Piping Sump / Trench Sensor(s). Model: t//L _V ❑ Piping Sump /Trench Sensor(s). Model /ice ❑ Fill Sump Sensor(s). Model- 0 Fill Sump Sensoc(s). Model: Mechanical Linc Leak Detector. Model: 6-c/tn) echaniad Line Leak Detector. Model & T F.� O'Electronic Lane Leak Detector. Model- ❑ Electronic Line Leak Ddectoc Model: ❑ Tank Overfill / high-level Sensor. Mudd:��"' 61Sa div �'I'—ark Overfill 1 Hi Model: ❑ Other (specify equipment type and model in Section E on PaLe 2)• 0 Other (specify equipmenteand model in Section E on PaLc 2). Tank IDs ✓ Tank ID: ❑ In -Tante Gauging Probe. - IModck ' O A, A . `,-= ❑ In -Tank Gauging Probe Model - 0 Annular Space or Vault Sensor. Model a 57 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump /Trench Sensor(s). Model'—I/2 .2 aP ❑ Piping Sump / Trench Scnsoa(s). Model: ❑ FilI Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mod& LVN Mechanical Line Leak Detector. Model: 7* 722 I ❑ Mechanical Ube Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / Hig or. Model: O C't ,s. gz r � y,,y ❑ Tank Overfill / High -Level Sensor. Model: Cl Other (s ui t and model in Section E on Page 2). ❑ Other (s ui t and model in Section E on Pa c 2). Dispenser ID: Dispenser ID: 3 11 Dispenser Containme Sensor(s). Model: ❑ Dispenser Containment ScrWr(s). 'Mod Shear Valve(s). Pd'i Shear Valve(s). Dis set Containment Float(s) and Chain(s). -6 Di ser Containment Floats) and Chain(s). penser ID: F0L Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s). Model•Shear Valve(s). ❑ Shear Valve(s). ❑ Dise2ser Containment Float(s) and Chain(s). ❑ ME= Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s).. ❑ Shear Valve(s). ClDispenscr Containment Flea(;) and Chain(s). ❑ Di Containment F12at(s) and Chain(s). *If the facility contains more tanks or dispensers. copy this form. Include information for every tank mid 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) nary to ®erify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of putrating such reports, I have also attached a copy of the repo�rU.(check all that apply): O$ystem set-up eport Technician Name (print): I, aa tj Signature: CeNtication No.:. <,f 0 :Z5_3 � License. No.: 0,?- o? Testing Company .Name:aba- mo\ e �nUerar-%CgLr Site Address: 25 Z S t:�_ c�ur��,k®u c�_ �:it•�n�,.k CA Phone No.: (B1b_) &&Q - 11C Date of Testing/Servicing:11'47 d 2_ Pa,c i ut 3 u ins l \I�tnit��riu_ �. acni Certification