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MONIT 'G' S' YSTEM C ATHtATION 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. If more than one monitoring system control panel is installed at the facility, 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. Instructions are printed on the back of this page. A. General Information FacilityName: CL' p it-!Z{ Bldg.No.: ry/_ Site Address: City:J& J Zip: Facility Contact Person: �,, rA fix. ' Contact Phone No.:(2123—) 2 2-x35-7 Make/Model of Monitoring System: C` A QZ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: 9. Q In-Tank Gauging Probe. Model:_ A<; 1211 In Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: AC_ RP Annular Space or Vault Sensor. Model: U 4=61 23 Piping Sump/Trench Sensor(s). Model: 5WR: 10 Piping Sump/Trench Sensor(s). . Model: 2utS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model:_�l Q Mechanical Line Leak Detector. Model: Ax/tJ ❑ Electioiiic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: W Tank Overfill/High-Level Sensor. Model: Qca q(vy ® Tank Overfill/High-Level Sensor. Model: CRA t<X., ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Id Shear Valve(s). Q Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ 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: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). 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 Site Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(check all that apply): 4System set-up report; All Alarm history report. Technician Name(print): %X.1 5�1I Cert./L.ic.No.:< 2n&�, Signature: Testing Company Name: Phone No.: Wit C11,M-01 Pnoe 1 of 3