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MONITORING SYSTEM CERTIFICATION For Use By All 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 mast 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 trust submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: aetlean Bldg.No.: Site Address: y0d ajjj,/ City: ceT Zip. Facility Contact Person: Contact Phone No.:( ) Make/Model of Monitoring System:I/P'Ji,r- 4e i- Date of Testing/Servicing: LL/-LL/-Cl B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Ins ected/serviced: T nk ID: &ALAII Tank ID: 011 In-Tank Gaugi g Probe. Model: In-Tank Gauging Probe. Model: - U- Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Rl Piping Sump/Trench Sensor(s). Model: 41 Piping Sump!Trench Sensor(s). Model: S- Fill Sump Senson s). Model: ]o Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Others eci a ui ment a and model in Section E on Pae 2). 0 Others 6 equipment a and model in Section E on Page 2). Tank ID: o . Tank ID: In-Tank Gauging probe. Model: - Cl In-Tank Gauging Probe, Model: Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: 19 Piping Sump/Trench Sensor(s). Model:79 j 3d- 0 Piping Swnp!Trench Sensor(s). Model: RaFill Sump Sens-or(s). Model:79 V.jfld-Ltsk 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment a and model in Section E on Pa&e 2). 0 Other(specify equipment and model in Section E on Pae 2). Dispenser ID: 1- Z Dispenser ID: MDispenser Containment Sensor(s). Model: Ir )0 Dispenser Containment Sensor(s). Model: d - 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dis enser Containment Floats and Chains . 0 Dispenser Containment Floats and Chain(s). Dispenser ID: 3-1 Dispenser ID: OL Dispenser Containment Sensor(s). Model: - 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dis enser Containment Floats and Chains . 0 Dis enser Containment Float(s and Chain(s). Dispenser ID: - Dispenser ID: 91 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment SenaOr(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). 0 Dispenser Containment Floal(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 -1 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,1 have also attached a copy of the repoJy (cyeck a rl t apply): Z System set-up !V his report Technician Name(print): ,A{� l�' Signature: P ' Certification No.:;)6 6 6 License.No.: 491948 Testing Company Name: CENTRAL PETROLEUM MAINTENANCE Phone No.:( 925 ) 462-4060 Site AddressA y&I dA1LA r41J,- T ,v Date of Testing/Servicing:_L�jJL /l2? UN-036-1/4 Page I of 3 Rev.06/04101 www.unidocs.org