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MONHORING SYSTEM CERTIF*ATIONRIECENIED s For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter /6, Division 3, Title 23, California Code o} A*1 ,2004 This form must be used to document testing and servicing of monitoring equipment. A separate certification oaWL QNTp*A{eTc}j for each monitoring system control panel by the technician who performs the work. A copy of this form must bITc SERVJgE$tk system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Or� tJ '��OC�p.S Bldg. No.: Site Address: t City:CIL TCSty Zip: g750`z16- Facility Contact Person: Contact Phone No.: (893 96q -SP0Q48 l� Make/Model of Monitoring System: Date of Testing/Servicing: a3 -If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessar to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi nt capable of enerating such reports, I have also attached a copy of the report; (check all that apply): System set-up A rm ry rt rt tj01 r.- Technician t Technician Name (print): L: A(A a�� q Signature: 'r . --� Certification No.: License. No.: -- AZ Phone No.:(� Testing Company Name:®nrv2�oa�>,d�av9—,L �) t�G3 ria C O ` > F,S i Site Address: 1.590 PvCCe,4_T &r., SSTOS I -,-roll !1,914"• Date of Testing/Servicing: i2_/301/03 Page 1 of 3 Monitoring System Certification 03/U i B. Inventory of Equipment Tested/Certified Check the aeeroeriate boxes to Indicates ecifle a ul ment tris ected/serviced: _ - Tank I D: 01: E-5T_L VL .,t Tank ID: In -Tani: Gauging Probe. Model: 17`Y10 - (p') ❑ In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 3!i! f25n —1420 ❑' Arinular Space or Vault Sensor. Model: A Piping Sump / Trench Sensor(s). Model: :32!!( 7Rb • Lam$ O Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 54 Mechanical Line Leak Detector. Model: fr o'° 14-, ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 5T? . 0 L0 �--1— ❑ Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model•- ElTank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment ne and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2), Tank ID: Tank ID: ❑ In -Tani: Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: O 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 (specify equipment type and model in Section E op Page 2). O Other (specify equipment type and model in Section E on Page 2). Dispenser ID: R i5R ` Dispenser ID: Q Dispenser Containment Sdtisor(s). Model: Xj 4?A0 _ ❑ Dispenser Containment Sensor(s). Model: A Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). ID: Dispenser ID: rDispenser ❑ Dispenser Containment Sensor(s). Model O Dispenser Containment Sensor(s). Model. ❑ ShearValve(s). ❑ Shear Valve(s). ❑Dispenser 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/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessar to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi nt capable of enerating such reports, I have also attached a copy of the report; (check all that apply): System set-up A rm ry rt rt tj01 r.- Technician t Technician Name (print): L: A(A a�� q Signature: 'r . --� Certification No.: License. No.: -- AZ Phone No.:(� Testing Company Name:®nrv2�oa�>,d�av9—,L �) t�G3 ria C O ` > F,S i Site Address: 1.590 PvCCe,4_T &r., SSTOS I -,-roll !1,914"• Date of Testing/Servicing: i2_/301/03 Page 1 of 3 Monitoring System Certification 03/U i