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� c MONIARING SYSTEM CERTIF ATION l For Use By A11 Jurisdictions Within the State of California 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 separate certification or report must be prepared 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: (-)A)1-FsPz vj:M�2Qi0 Bldg. No.: Site Address: N q n LC d 1-L ST-; City: Zip: q5g 15 Facility Contact Person:�!� T(-�� i L V ER, ►vtt Contact Phone No.: (39 ) of hLt-,$BOO *8&`iS f F- Make/Model of Monitoring System: Q �zQ - Rat,T TL.3,S,--0 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate hoses to indicate specific equipment inspectedtserviced: Tank [D: D% E U' 'TAiP 1,. 0 1 _ Tank ID: X In -Tank Gauging Probe. Model: 6-17,31& ' ivy ❑ In -Tank Gauging Probe. Model: _ �9 Annular Space or Vault Sensor. Model: A5N25jo --142O ❑ Annular Space or Vault Sensor. Model: Q� Piping Sump / Trench Sensor(s). Model: -35t/ 2XC) • 2-6 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 64 Mechanical Line Leak Detector. Model: ' �� QtsMo'�Qtipt s ., CJ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 5TV -- f'I L0 ❑ 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 on 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: ❑ 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Oy5gera3r ` m % Dispenser ID: Q Dispenser Containment Sensor(s). Model: 374 p --2-08 ❑ 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ 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). *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) necessa to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equip nt capable of enerating such reports, I have also attached a copy of the report; (check all that appl$� A rmy�ry r ort �jC& t�50-1 1E� Technician Name (print): �jlg rJ CGS(3;J Signature: h. Certification No.: 90,T-6 License. No.: -14A;z- 4A 338 j Testing Company Name: a�� iile9e�MENt-/�L ��C� JL► C.r Phone No.:(9, d ` 68j-6-)0'6 _ Site Address: /'.5 90 PXCCeLs 13-r 9 Date of Testing/Servicing: 12-/-80 /0 Page l of 3 03/01 Monitoring System Certification