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ID [RECENED MONITORING SYSTEM[ CERTIFICATION AIA 0 4 2069 For Use By.4/f Juri.sclictions if,'ithin the.State of Calybrnio ` ' f4iE �.HEALTH .-luthority Cited: Chapter 6i.7, Health anrl&rfeh)Carle; Chapter 16, Divradon 3, Title 23, Ccdiforraicr`�'p{�r�Y��MES 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•ofthis 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 IDfarmation Bldg.No.: Facility Name: Site Address: © vli dr �°! � Yl P City: 6 - Zip: CL _q2� Contact Phone No.:( ) Facility Contact Person: Make/Model of Monitoring System: Date of Testing/Servicing: R. Inventory of Equipment Tested/Certified Check thea)n-o nate boxes to indirate s recitic a ui ment ins ected/serviced: Taal � 14 Tank I D: ❑''Iy.F,nk Gauging Probe_ Model: M-Tn_Tank Gauging Probe. Model: A}�ular Space or Vault Sensor. Model: 3f?O � uI -Space or Vault Sensor. Model: Ga'f'iping Sump/Trench Sensor(s). Model: 7-4 iping Sump I Trench Sensor(s). Model: Ell Sensor(s). Model: Cl Fil ump Sensor(s). Model: echanical Line Leak Detector. Model: echanical Line Le, Model: �- C7" ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Madel: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ci' e ui tnent t e and model in Section E on Pa a 2). ❑ Other(specify e tti meat ty e and model in Section E an Pae 2). + Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: a-fil--T-anl:Gauging Probe. Model. All Ll Annular Space or Vault Sensor. Model: ❑ lar Space or Vault Sensor. Model:5 ❑ Piping Sump/Trench Sensor(s). Model: UrTiping Sump/Trench Sensor(s). Model: GQ Fill Sump Sensor{s). Model:. L3 Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1.High-Level Sensor. Model: 0 Tank Overfill I High-Level Sensor. Model: _ Other(s ecifi'ei uipment ty a and modet in Section E on Page 2). ❑ Other(specify equipment ty a and model it,section E on Page 2). Dispenser ID: l �-- Dispenser ID: - ❑ Dispenser Containment Sensor(s). Model:_ ❑ Dispenser Containment Sensor(s). Model: ,� Shear Valve{s}. � Shear Valve(s). `'� Dis enser Containment Float(s)and Chain(s). tA Dispenser Containment Float(s)and Chain(s). j�`- Disperser ID: Dispcnscr ID: — ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model; ❑ Shear Valve(s). D 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: _ C I Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dis user Containment Flont(s)and Chain(s). =If the facility contains more tanks or dispensers,copy this form. Include informs n for every tankffd dispe iser at the facility. Certification - I certify that the equipment identified in this document was inspee a Iscrvtcedeeessaty to ver that this in accordance with the C. manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) n r3 Y information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such lar h�stox report reports,I have also attach d a copy of the report:(check all tlttrt npplb+): ❑Sy tit fav, Technician Name(print): Signature: o.: Certification No.: License,N Testing Company Name: 1 Phone No.:� oq Date of Testing/Servicing: f Site Address: 113fUt Page 1 of� !Monitoring System Certification D. Results of Testing/ServiciDt