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MONITOZING SYSTEM CERTIATION For F-By all Jurisdictions Wiihin the State of Cao yornia, -Df . .-1 urltot-itl= Cired; Chapter 6.7, Health and Safety Code; Chapter- 16, Division 3, Title 23, Caii/orniu Code oj'Regulutiwas this forin aiust be used to document testing and servicing of monitoring equipment. A sepgjata certificationr, e tst b Cor ouch monimrine system control panel by the technician who perforans the wot-k. A copy of this fb'rm 1 st be"'ftvided to the tali". system owner/operator. The owner/operator must submit a copy of this form to the local agerjcy regulating UST s�r�Tems within :)u _ I days or test date. �EI�NIITISFR1nr�a-,-. A. C.enera�l Information Facillty Name: 59it 14,17- Bldg, No.: _ Site _address: 3fo 7 f�?af J,�' — _ City; G Zip: —_ Facilir�- Contact Person: Contact Phone No.: IvIaLe:Niodel of Ivionitoring System: �_ ocl Date of Testing/Servicing: I !U & Inventory of Equipment Tested/Certified L.les!,clic :,D ro riate boxes to iadlcarc specific equip mrut lits�ected/serviced; l':rnl.LD: t,6T—_.. jX44- _. , Tank ID: ` lia 'funk t;mauging Probe. Model: &I¢ / In-Tari Gauging Probe. Model: $tfrl - 1S_vnnu[Lit Space or Vault Sensor. Model:_343 A Annular Space or Vault Sensor. Model: 5 can _ XPiping Sump/Trench Sensor(s). Model: ;Piping Sump/Trench Sensor(s). Model: '�4 C V C1 rill Srurrp Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Irlach.utioal Line leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: ❑ L`lccuotsic line leak Detector. Model: U Electronic Line Leak:Detector, Model: - f 0 Lank Overfill/High-Level Sensor. Model; ❑ Tank Overfill 1 High-Level Sensor. Model: - Q Others Zeit,e ui ment t e and model in Section L on Page 2). ❑ Other s eci', a ui mem t e and model in Section E on Pa6c 2) 'funic ID: _ Tanlc ID: lit-1'ank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Modcl: J Umular Space or Vault Sensor, Model: Q Annular Space or Vault Sensor. Model: 1 Cl Piping Sump/Trench Serasor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model;ci Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model; --- 0 Alechzinical Line Leal:Detector, Model; ❑ Mechanical Line Leak Detector. Model: Cl l:lecrruuic Line Leak Detector. Model: ❑ Electronic Line Leak.Detector, Model: CJ T:uik Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ ❑ E:rher is eciti ea ui menr type and model in Section F, on Page 2), ❑ Other(specify e ui ment type and model in Section E on Pe AC ?) Dispeaser Ill: _ Dispenser ID: ❑ Dispenser Containment Sensor(s), Modei: ❑ Dispenser Containment Sensor(s), Model: U Shear valve(s). ❑ Shear.Valve(s). _-- 0 l),s)eraser Containmenr Float(s)and Chain (s). ❑ Dispenser Ccniai mtnt Float(s)and Chitins I Disptostw 1D: Dispenser ID: ! 1 ❑ Dispenser Conlaitunent Sensor(s). Model: 0 Dispenser Containment Sensor(s), Model: v Shear Valve(s). ❑ Shear Valve(s), ❑ Disp enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain (s). + Dispenser Ill: Dispenser ID: 0 Diypanser Containment Sensor(s), lVfodel: ❑ Dispenser Containmenr Sensor(s). Modcl: U sh=V1Jve(s). ❑ Shear Valve(s). -- C]Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Flora[ s and Chains . 'If the rr4ility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. w 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 informatiun o correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, r liaN a .kin :,[ruched a cupy of the report; (check rr/l that rappry): System set-up 1 rm h' to report [och aician Name (print): I—) Signarure: Celtiiication No.: License. No.: 3�Jp7s '4 �4a Z Testing Coll)pally Naane: Wan '��,��-rn�y Phone No.:( �61 --- Slas .lcitiress: h-07( /�✓ice-- S TOGi A2fC; (�'� Date of Testing/Servicing: / Je Page 1 of 3 03x 14louiturill g System Certification