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MON11106MG SYSTEM ' c ,` 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 12Mpared for each monitoring system control panel by the technician who performs the work. A copy of this foam 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 Info on Facility Name: Bldg. No: Site Address: 4z a City: Trp: 4?S Facility Contact Person: VAAA,5v Contact Qone No. Make/Model of Monitoring Systen'r 6AZ Date of Testing/Servicing: J B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins serviced: Tank ID: Tank ID: 99 In -Tank Gauging Probe. Model: In Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _P 2 4TI Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: 791sq 6 Piping Sump /Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: C>10 Mechanical line Leak Detector. Model: AIV 9 Electronic Line Leak'Detector. Model: Electronic Lane Leak Detector. Model: .0 Tank Overfill / High -Level Sensor. Model: _ ( l!CX i 10 Tank Overfill / High -Level Sensor. Model: —r%gA ln(.z, ❑ Other (setifj 2qui ment type and model in Section E on Pa e 2). ❑ Other (specify!NuiLment type and model in Section E on Page 2). Tank ID: ze Tank IID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: 4 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: a/ ❑ Mechanical line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: n � ❑ Tank Overfill / High -Level Sensor. Model: Other (sEEia equipment = and model in Section E on Page 2). ❑ Other (s iEquipment type and model in Section E on Pa a 2). Dispenser ID f" Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 41 Shear Valve(s). ❑ Shear Valve(s). Dis nser Containment Float(s) and Chain(s). ❑ Dispenser 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). ClDispenser Containment Fldat(s) and Chain(s). ❑ Dispenser Containment Floats) ana Chain(s). *If the facility contains more tanks or dispensers, copy this form Include information for every tank and 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) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any eq 'pment capable of generating such reports, I have also attached a copy of there , (check all apply): System set-up Alarm history report Technician Name (print): y �� Signature: Certification No.: 5_61- 7130 f� License. No.: Testing Company Name: /c, ;are,�_/nx�os•��.xat�.aQ � ��;,� Phone No.: Site Address: 1(5:3 f; ,� �rJ ('t,� Date of Testing/Servicing: 2 \lunit�n ink ��.;�:n Crrtifi�•aticm