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ONITO SYSTE "E I N _ For Use By ll jt Within the State of Califo lifomia Code of Regulations Authority Cited. Chapter 6.7, Health and Safety Code,. Chapter 16, Division 3. Titte 23, re aced This form must be used to document testing and servicing of monitoring equipment A o�tBc`''tion u or ren�rt m f r each monitorin tem contr 1 l by the technician who performs the work. A copy of this form must be provided to the tank y o sane copy Y g y regulating UST systems within 30 system owner/operator. The owner/operator must submit a eo of this form to. the local a enc regu g Y days of test date. A. General Facility Name: Site Address: Z- '-' e Facility Contact Person: y ■ ] [ �!i Bibae Make/Model of Monitoring System: ried B. Inventory Of Esq o1Pm ris2Teflc u, men, Insgecl Tank ID: Modal: &ln-Tank Gauging Probe. Model: �- a Annular Space or Vault Sensor. /Trench Sensor(s). Model: in Piping Sump Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. O Electronic Line Leak Detector. Mdel:-�6+tn gLeJt1� O Tank Overfill / High -Level Sensor. Mode' and model in Section E on Pa a 2). ❑ Other (st�i ui ment _ Model: _._____---- Tank ID:Model: ❑ in -Tank Gauging Prod Model: ❑ Annular Space or Vault Sensor. / Trench Sensor(s). Model: C) piping Sump Model: O Fill Sump Sensor(s). mel O Other (spec O Mechanical•Line DDetector. Model: r. ❑ Electronic Line Leak vel Secto cnsor. O Tank Overfill / High -Le Model: in Section E on Pa e 7). ❑ Other (spcci ui mcnt t and model Dispenser ID: Model: ❑ Dispenser Containment Sensor(s). O Shear Valve(s). O Dis user Containment Float(s and Chain(s). Dispenser ID:Model: ❑ Dispenser Containment Sensor(s). O Shear Valve(s). Cl Dispenser Containment Float(s) and Chain(s). — Dispenser ID: Model: ser Containment Sensor(s). Bldg. Zip: Contact Phone No.: ( --) � j � �?' � Date of Testing/Servicing: Lo-12-cll___.1- Tnaak ID:n Probe In-Tank Gaugi g . Model: Mooddel: O Annular Space or Vault Sensor. / Trench Sensor(s). O Piping Sump Model: O Fill Sump Sensor(s). O Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. O Tank Overfill !High -Level Sen Model: del in Section E on Pa O O� s if ui mcnt t pe anrd Tank ID: O In -Tank Gauging Probe. MdeL _------ O Annular Space or Vault Sensor. / Trench Sensor(s). _ Model: _._____---- ❑ Piping Sump Model: _�------- O Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. ------ Model: _------- ❑ Electronic Line Leak Detector. _ Model: O Tank Overfill/ Hi hm ni Sena�d SectioEon Pa mel O Other (spec Dispenser ID: Mod, -I:. O Dispenser Containment Sensor(s). O Shear VSIve(s). O Dis Containment Float(s) and Chain(s Dispenser ID: Model: ❑ Dispenser Containment Sensor(s): Cl Shear Valve(s)- 0 Dis Containment Floats) and Chain(: Dispenser ID: `Model: O Dispenser Containment Sensor(s). ❑ Shear V$IYe(s). O Dupcn ❑Dis Containment oat(s) and Chain( O Shear V alve(s). on for every tank and dispenser at the facility. ❑Dis Containment F►oat(s and Chain s)• this form. Include info tmad manufacture -If the facility contains more tanks or dispensers, copy twas inspected/se 'ced in accordance with �� tion is necessa to verifreports, I have also C. CertifiCatlt)ri - I certify that the equipment identiCe In document am' cite zpable generating such repo guidelines. Attached to this Certification is ir�rma rnent. For any equip tin hist r rt correct and a Plot Plan showing the layout of monitoring set ygtem set-up attached a copy of the repo -0; (check all d at plY)t f Signature: Technician Name (print): �''a'� License. Certification No.: Phone Testing Company Name: w Date of Testing/Servicing: Site Address: 6 3 03/01 Page 1 of 3 Monitoring System Certification -- M 14 Al -FCA