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RECOVED ONIT NG SYSTEM CERTIFIATION For Use By All Jurisdictions Within the State of California JAN 2 2 2007 Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o Regulations VI T HEALTH This form must be used to document testing and servicing of monitoring equipment. A seoarate certificatio epared 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. A. General Information Facility Name: E_C evNjZ`., 6A _5 Bldg. No.: Site Address: Un \1tCt-o4' Q d City: Loo \ Zip: ej J2 - n Facility Contact Person: S a0`c0_ Contact Phone No.: Make/Model of Monitoring System: W gaa VC,!:;L T Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: S6 -( Tank ID: � j 1 ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Wi Annular Space or Vault Sensor. Model: 22 %D - 3o l PLAnnular Space or Vault Sensor. Model: '71 `C -30 ❑ Piping Sump / Trench Sensor(s). Model: O Piping Sump / Trench Sensor(s), Model: O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model: ❑ Other (sEeciEZ a ui ment a and model in Section E on Pae 2). ❑ Other �!Eeci2 a ui ment =e and model. in Section E on Pae 2). Tank ID: Tank ID: O 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: _ O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: ® Tank Overfill / High -Level Sensor. Model: ❑ Other s eci a ui ment type and model in Section E on Pae 2). ❑ Other �s2ecia a ui ment =e,and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). O Dis enser Containment Float(s2 and Chains . ❑ Dis enser Containment Floats and Chain(s). Dispenser. ID: Dispenser ID: Cl Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains . 1 ❑ Dis enser Containment Floats and Chains . *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) nes to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment c able of enerating such reports, I have also attached a copy of the report; (check all that ply) ,.System set-up A Alar history eport Technician Name (print): , / ",Z_ 91,V.11 Signature: Certification No.: _ & 1-f-1 & !d License. No.: _433159 Testing Company Name: —B. Z. Service Station Maintenance Phone No.: (916_)371-2380 Site Address: 630 Houston Street W. Sacramento, CA 95691 Date of Testing/Servicing:� �O Page 1 of 3 03/01 Monitoring System Certification