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• • Rea MONITI€ R NG SYSTEM CE1ltHFI A"1'ION ✓U/V 2 p�� For Use By AMJrPisdictram Within the Stare of California gg ,,nn,, Authority Cited- Chapter 6.7,Health and Safety Code,-Chapter)6,Drvl3iftrt 3,T-rrle 23. CaiforniaBYl Wlr ,e,-u at45 This form must be used to document testing and servicing of monitoring equipment.A separate certification bit-"�Tr1mCb�YJilLeoifst nheAred for each monitoring system control panel by the technician who pm1brms the work_ A copy of this form must be pro system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems 30 days of test date- A. Genera[In f- 'on FacilityName: VAC-1$ Bldg.No.: Site Address: 1�o�at, City I,-- c--_ Zip: j Facility Contact Person: l h✓t 0 Contact Phone No.:(-g�j 96773 Make/Model of Monitoring System: !Ya _ tt 1 r, Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a -date bows to andacate ni cel' serviced: Tants m: - (c'"-- Tank ID: 0 � ¢ in-Tank gProbe. Model:QAo?t9/3?-60 _ �i In TankGaugingProbe. Model: Ad Qi Annular Space or Vault Sensor. Model:PaoS jj l"ir fOoo (,'�;Armular Space or Vault Sensor. Model:' Ao tCo� *Piping Sump/Trench Sensor(s). Model: o t KPipmg Sump/Trench Sansor(s). Model:i �OJ�i t7 * Fill Sump Sensor(s)- Model:r U Fill Sump Semwr(s)- Model: Mechanical Line Irak Detector. Model:�=F�c1 U ;KMechanical Line Leak Detector. Model:7T FX t Q Electronic Line Leak Detector. Model: Q Electronic Lite Leak Detector. Model: " 1H.Tank Overfill/High-Level Sensor. Model:opo-61 So,' (j;V Tank Overfill I High-izvel Sensor. Model: Q Odta equipment type and model in Seton E on Pw 2). Q otter(specify equipment type and model in Section E on P e 2. tg Tank ID: a Tank ID: 0 In-Tank Gauging Probe. Model:PACQa , t a ❑ In-Tank Gauging Probe. Model: � a Annular Space or Vault Sensor. Model-?A&3-"11 YWoe> Q Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model.aMd*7 olee,C O Q Piping Sump/Trench Sensor(s). Model i 0 Fill Sump Sensor(s). Model- 0 Fill Sump Sensor(s). Model if Mechanical Line Leak Detector. Model: _ fry 1 V 13 Mechanical Late Leak Detector. Model: Q Electronic Line Leak Detector- Model: - U Electronic Line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: D P w 6 i 1 Q Tank Overfill!High-Level Sensor. Model: Q Other(specify equipment and model in Section E on a 2). Q Otho noel model in Section.E on Pa e 2)- Dispenser ID: Dispenser ID: Q Dispenser Containment Sutmr(s). Model: U Dispenser Containment Sensor(s). Model; Q a Shear Valve(s). ALShear Valve(s). DiContainment Flo s and US- Dispenser . - Containment Float(s)and Chains. I Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s)- Model: Q Dispenser Containment Sensor(s). Model: Q Shear Valve(s). iJ Shear Valve(s). Q - 'nut Containment Fl Ch sand ain(s1- D - Containment E!2asand Cbai s). g Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Modes: € Q Shear Valve(s). ❑ Sheat Valve(s). - LIDiEMMContainment E2ffLsl and Chain(s). ❑ Dispenser Containment Flo s and Chains. 'If the fac lity contains more tanks or dispensers,cop,this farm- Include information for every tank and dispenser at the facil ty. C. Certification-I certify that the equipment ident-Hied In this document was inspecredtsa-ked in accordance with the manufacturers' guidelines. Attached to this Certi iration is information (e-g. manufacturers' checklists) necessary to verify that the 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 411 rhd Wly) 0 System set-up L1 rm history Technician Name(print): T •,�5 ? k�Ic 'Signature: ��e.lt / 3— c.: Certification No.: `l'6,,9// License. Testing Company Name: C teS�C� i_ C�.n- �t �j vtt Picone No.: cRP9 ) 7 t[t Site Address: �6 ^ice 7 SSS M r� � - "�!=G+F .2e'' 206 Date of TestittgiServicing: 6 !3 f o 3`— Page 2 of 3 03Ai Monitoring System Certification