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MONIT&ING SYSTEM CERTIFIATION . For Use By All Jurisdictions Within the State of California ��/. j' Authority Cited:Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California C60 ,pf Reguilati To',� This form must be used to document testing and servicing of monitoring equipment. A separate certification ofefic►be,re� pared for each monitoring VAtem control panel by the technician who performs the work. A copy of this form must be piovided,*' system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems';14ti 0 days of test date. A. Genera Facility Name No.. Site Address: I 1 B C_ Ok % np-A City: C oVZip S ok S Facility Contact Person: Contact Phone No.: (a 6� , 3 i ' Y k o 1 Make/Model of Monitoring System:yPP eiP_ - b0 i . Tt.,S 3 5 O Date of Testing/Servicing; B. Inventory of Equipment Tested/Certified f Check the appropEiate boxes to indicates cific quipment inspected/serviced: Tank ID: ' D 1 e, N Tank ID: In -Tank Gauging Probe. Model: O ' � CA ❑ In -Tank Gauging Probe. Model: .Annular Space or Vault Sensor. Model: —42c) ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 7 O O ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: CA Mechanical Line Leak Detector. Model: STP-M1.O ❑ 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: Cl Other (s eci equipment a and model in Section E on P e2 . ❑ Other (specify equipment a and model in Section E on Pa e 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 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 (s eci a ui mentand model in Section E2! Pa e 2). ❑ Other (sUcify a ui ment W and model in Section E on P e 2). Dispenser ID: D !s* � _ Dispenser ID: ,1a Dispenser Containment Sensor(s). Model: 7" 0 -C> ❑ Dispenser Containment Sensor(s). Model: PS, Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Q Dispenser 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). UDispenser Containment Floats 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/serviced 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 Pian showing the layout of monitoring e�qquipment. For any equipment capable of ge ating such reports, I have also t apply): Zi System set-up W A h re rt attached a copy of the report. (check=Q�) Technician Name (print): 2 S o,Signature: ...... �— Certification No.: License. No.: 'tb Q Testing Company Name: �'nVlrprw�yl 1 JVCS �v�C • Phone No.:O S t (08(_0_70b Date of Testing/Servicing: 16 / OS/ O S Page 1 of 3 83/01 Monitoring Svstem Certification