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L • MOI" I'I'OI�ING SYSTEM CERTIFI l TION For Use 13v. 11 Jurisdictions It'itl7irt the ,Stale of C'(1lifbrnict SEP N08 a Atllhorillv C'iled: C'hctpler- 6.7, f/e0/1h ane% Safeo) Code; C'hapler 16, Division 3, Tille 23, California Code of'Rc uiltwons _ This torn, must be used to document testing and servicing of monitoring equipment. A separate cert rt •� D ust bes,�: HI prepared for each monitoring system control panel by the technician who performs the work. A copy of this dr'iii ini'j 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 E - Facility Name: a o -o ' t .i Bldg. No.: Site Address: 2512 -V` ®0Qy City: �(' �Zip: 7}52 1 Facility Contact Person: Contact Phone No.: ( Z011 )ALI )AL — Make/Mode( of Monitoring Syster tom[} Date of Testing/Servicing: D. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecil➢c a ui ment ins ected/serviced: T' nk ID: `P K) L— Tank ID: In -Tank Gauging Probe. Model- In -Tank Gauging Probe. Model: < Annular Space or Vault Sensor. Model: F i_S Annular Space or Vault Sensor. Model: E 1,--? Piping Sump / Trench Sensor(s). Model: Ol,�; 'Piping Sump / Trench Sensor(s). Model: lel 4 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ` ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: L� Zt>�0 ❑ Electronic Line Leak Detector. Model:❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model:❑ Tank- Overfill / High -Level Sensor. Model: ❑ Other (s cify equipment ty a and model in Section E❑Other ZPa, (s eci a ui mint t e ar�d model in Section E on Page 2). Tank ID: Tank ID: D .❑ In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor Model:/Annular Space or Vault Sensor. Model: w 6 ❑ Piping Su np / Trench Sensor(s). Model:la Piping Sump / Trench Sensor(s). Model:UL❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:Is ❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: L --j) 2 E)—t ❑ 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[ equipment ty a and model in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Pa a 2). Dispenser ID: ' 2-- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model i)1 S ❑ Dispenser Containment Sensor(s). Model: VAS El Shear Valve(s). El 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). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 1,❑ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). UDiseenser Contaimnent Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this fonn. hiclude 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 Plan showing the layout of monitoring equipment. For any equipment. capable of generating such reports, I have also attached a_copy of the report; (check n0 that applp): ❑ S st setp� ; LJ Alarm history r ort Technician Name (print): Felix Ramirez Signature: Certification No.: 2� ? '� License. N OTT # QS -1740 ICC# 5273934 -UT Testing Company Name: AV F Phone No.:� 2 r 'i ) � � s D I t z, Site Address: `�� Z�� #�- Date of Testing/Servicing: Page 1 of 03101 Monitoring System Certification D. Results of Testing/Servicing