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MONIT&ING SYSTEM CETIFIC ION 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 a 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. y A. General Information Facility Name: C✓Il_L ! G Y( C G v4 Bldg.No.: Site Address: 2,S S / 113u t re lqyC City: ,Y xAgif' a Zip: Facility Contact Person: A7,09i ZyZ,6j= S'®/V Contact Phone No.: 2,7j`7 f 79 Make/Model of Monitoring System: S)(?CAj /4 cA i $' / Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a ro riate boxei to indicate specific ui ment Ins ed/serviced: qTa ID: ! Tank ID: ^19 I//n:Tank Gauging Probe. Model:']w 6cls® 6 _ ❑ In_Tank Gauging Probe. Model: tit' nular Space or Vault Sensor. Model:_ 2'd f3 7 4't4/: 1 1- E3 Annular Space or Vault Sensor. Model: t]3 Piping Sump/Trench Sensor(s). :Model: Fl QA1 Ye.,� cA, El Piping Sump/Trench Sensor(s). Model: 7 _ ❑ 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: ❑ Other(sgecifX a ui ment t2, and model in Section E on Page 2). ❑ Other(specify a ui ment tv pe and mode!in Section E onPa a 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 jyine 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: ❑ Other(s eci ui ment t-ype and model in Section E on Page 2). ❑ Other,(!Recify a ui ment=and model in Section E on Pa a 2). 'Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). U_pjspenser Containment Float(s)and Chain(s). ® Dig en set 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). ❑ Dis nser Containment Float(s)and Chain(s). ❑ Dis nser 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). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and 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/servieed 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 or monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Aar his = y o - Technician Name(print): Z,�4 �°7" ✓tn1 Signature: Certification No.: _g(2 Y License. No.: Testing Company Name: i9 Ianozy TRIiyk 701•/7.1!q Phone No.:(g0Q ) 6GC➢ Site Address: 1,90. nBk 110 s� S'�- , CA 'i�M?_705'T Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification