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Oft MONITORING SYSTEM CERTIFICATION For Use By.411 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. if fnefe - hperforms the work. i t _mi4—a Al separate certification or reRoort must be prepared for each m nito = s tr 1 y who p tht form to the local enc A copy of this form must be provided to the tank system owner/operator. The r or tL. y regulating UST systems within 30 days of test date. ' A. General Information '�r_ ' 2016 Facility Name: lJe. �'0�� -Aldg.No.: Site Address: 1 AIC149 -" Zip: Facility Contact Person: f elk-\ C two Make/Model of Monitoring System: �[t:,Ps kr � �5�� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the ageropriate boxes to indicate specific equipment ins ected/seniceds: Tank ID: Tank ID: Q ❑In-Tank Gauging Probe. Model: ❑ Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4 El 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). 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: i ..Z Dispenser ID: �)-t-{ ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Serisor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: -1_1W ❑Dispenser Containment Sensor(s). Model: _15zor4 ❑Dispenser Containment Sensor(s). Model: "'?pa ❑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 Float(s)and Chain(s). *Ifthe 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 84e-Plot Plan showing the layout of monitoring equipment. For any equt ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ® System set-up W Alarm history report Technician Name(print): Tony Fontana Signature: Certification No.: V.R.A23686 ICC 1064273-UT License.No.: A-846288 Testing Company Name: U.S.T. Compliance Testing Inc. Phone No.: (209) 595-4489 Testing Company Address: P.O. Box 580 Ceres, CA 9=7 Date of Testing/Servicing:I;)—F1� l L UN-036-116 w-ww.unidoa.org Rev.01/17/08