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Monitoring yste Equipment Certification For Use By All Jurisdictions Within The State of Caf#brnia 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 A sanarate certification or regort must be prepared for each monitoring system con of 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 system within 30 days of test date. A. General Information Facility Name: e -A1 0ilV0e-+- Site Address: Bldg. No.: '&17 City Zip• 9 S: Facility Contact Person: Contact Phone No,: Make/Model of Monitoring S 3 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the aooromiate boars to indicate soeeifie eouinment iu mected/servleed: Tank iD• Tank IQ:— In - Tank Gauging Probe, Annular Space Vault Sensor. Model: Model: In.- Tank Gauging Probe. Annular Space or Vault Sensor. Model: Modes: or Piping Sump \ Trench Sensor (s). Model: r iib Piping Sump \ Trench Sensor (s). Sensor Model: .? Model: Fill Sump Sensor (s). Model: V Fill Sump (s). ❑ Mechanical Line Lcak Detector. Model: a Mechanical Lane Leak Detector. Model: - Electronic tine Leak Detexor, Model: sl a • Ekotronie Una book Detector. Model:— Tank Overfill \ High -Level Sensor, Model: 10 Tank dve flil 1 High -Levi Sensor. Model: ❑ Other ( specify equipment type and model in Section Eon 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: W2 R ❑ Annular Spate or Vault Sensor. Model: xq Piping Sump 1 Trench Sensor (s). Model: I.O.Z ❑ Piping Sump 1 Trench Sensor (s). Model: i� Fill Sump Sensor (s). Model: i) Y ❑ Fill Sump Sratsor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Moobattical Line Leak Detector. Model: &i Electronic Line Leek Detector. Model: 5Mf X 13 Electronic Line Leak Detector. Model: ' 17 Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section Eon Page 2). ❑ Other ( specify equipment a and model in Section Eon Page 2). IQ; Dispenser ID - VDispenser Dispenser Containmerlt Sensor (a). Model r)7 DispenserConutunm Sensor (a). Model: Shear Valve (s). Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Moat (s) and Chain (s). Dispenser ®• 59W Dispenser ID• 1-3 Dispenser Containmeft Sensor (s). Model: ` Dispenser Containrfmn Sensor (s). r Sire" Valve (s). Model: ij Shear Valve (s). ❑ Dispense Containment FI (s) and Chain (s). ❑ Dispenscr ContainuneR oat (s) and Chain (s). Dispenser IQ: Dispenser ]D• Dispenser Containmefit Sgisor (s). Model:t7 S of Contain t Sensor (s). Model: Shear Valve (s). Shear Valve (s). ❑ Dispense Containment Float (s) and Chain (s), ❑ Dispcoser Cotntainment Float (s) and Chain (s). "If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispense at the facility C. Certification - f certify that the equipment identified in this document was laspectedlservieed in accordance with the manufacturer's guidelines. Attached to this Certification is Information (e g. manufactures' checklists ) necessary to verify that this information Is correct and a Plot Plan showing the layout of monitoring equipment., For any equipment capable of generating such reports, l have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alann history .reg rt Technician Name (print): ,iP • �-+c: ea Signature: Mfg. Cert.#. 3 -% 3 Q ICC# License. No, 485184 Testing Company Name: SSS Phone No : (408) 871-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: