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- � e MONITORING SYSTEM CERTMCATION •' For Use By All Jurisdictions Within the State ofCalifornia Authoru1Citd- Chaper 6.7,Health andSafey Code;Capter 16,Division 3,Tile 23,California Code ofReSu `io 4 . This form must be used to document•testing and servicing of monitoring equipment. If more one• monitoring system control panel is installed at the facility;a-separate certification Or report must be nr�eyared for . each moiiitoiing_system control panel by the teahniciaii who performs the work. A copy of this form must be provided to the tank system.owner/operator. The owner/,pperator 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 Facility Name: i CAL p ®® ' Z l Bldg.No� Sits Address: 40C City: Zip: Facility Contact Pcisou: Contact Phone No.:C ck' Make(Model of Monitoring System: 071%,L) SMC.- Date of Testing/Suvicing: B. Invetitoryof Equipment Tested/Certified Check the appropriate boxes to indicate e'equipment'ns serviced: . Tank W.- Tank M. Z„ 43'1x-TankGraugingProbe. Model: M!jf2 Tank. Probe. Modek Jar'Annular Space or Vault Sensor. Model: . 3oz: Space ory ur(t Sensor: Model: 36Z: IrpipingSump/TrenchScnsot(s} Model:" -Z_PS Sumplucnch (s). _ Model: ZQ� ❑-Fill Sump Seasoc(s),• - Model: ❑:Fill Sump s} Model: XMccbanicdLine Leak Detector. . .Model: k 'calLineLeakDeter. Model: ❑ ElectronicLincLeak Detector.. Model: . ❑Egaropic LineLeakDGcdor. Uodel: O Tank overfill/High-Ledet.Seasor ModeL- ❑Tank overfill I0&-Level Sensor Model: ❑ Dispenser•Contaimnent Scasor(s). .ModcL _ ®.Dispcoser Containment Scnsor(s). Model: ❑ Shear Valve(s). 0 Sherr Valve(s): ❑ Dispenser Containment Floats)and ahain(s). O DiWeaser t Floats)aad Cham(sj . ❑ Other(specify equipment type and model in Section E on Page.4• ' :. ❑Other(specify ee{nipinent type and model in SectiotiE go Page 2)..' Tank ID: Tank ID: ❑ In Tank Gauging Probe. Model: O In-Tank Gauging Probe. . 'rModel: ❑ Annular Space or Vault Sensor. . Model: ❑•Annular Space or Vault Sensor. •Model- ❑ Piping Sump/Trench Scnsor(s). Model: - ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sc nsor(s). Model: ❑ Fill Sump Seasor(s). Model: ❑.Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector.. .Model• . 0 Electronic Line Leak Detector. Model: ❑ Electronic lane Leak Detaxor. Model• ❑.Tank overfill/High:Level Sensor. Model: ❑Tank overfill/1ligi4..,7e1 Sensor. Model• ❑ Dispenser Containment 4 Model: ❑ ent Seasor(s). Model- ❑ Shear Valve(s). ❑Shear-Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ® Dispenser Cobblament Floats)and Chain(s). •. Q Other(spocify alolpmtype mad model in Section E onPap 2): O Other( type and model in Section E on P09Q2). G 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 (eg. manufactur+erV checklists) accessary to verify that this information is correct and a.Site Plan 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): ARrSystegi set-up report; Marin history,report Technician Name(print): r(e S" �-e- • • Certn ic.No.: Signature: so _ Phone'No