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MONWORING SYSTEM CERTIFWA For Use By All Jurisdictions 119drin the Stale of'Calijornia Authority Cited: Chapter 6.7, Heal/h crnc% S'nfety Code; Chapter 16, Division 3, Tide 13, CIM lations This form must be used to document testing and servicing of m ngcpgxppmegyawcc prepare for each monitoring system control panel by the technician uqh pye prov the tank system owner/operator. The owner/operator must submit a copy o this oral within 30 days of test date. "� l mono e.rxxe.�.0 Ti �'r5 APP 1 d )nno u n7sonn� A. Genera Facility Name Site Address: Facility Conte Make/Model ( to B. Inventory of Equipment Tested/Certified Check the iperoariate boxes to indicatespecific equipment ins ected/serviced: T:m Gauging Probe. Z O O n- Model: Ud'fn-Tank Gauging Probe. Model: �2[ peL� �ar Space or Vault Sensor. Model: 7A'H 7 -NO'k n r Space or Vault Sensor. Model: 7rya! 21A�-:,,rO99 ®'Piping Sump / Trench Sensor(s). Model: - o Sump / Trench Sensor(s). Model: 30 ft- ❑ FijjMmp Sensor(s). Model: El Fi Sensor(s). Model: echanical Line Leak Detector. Model: echanical Line Leak Dk*t ior. Model: �p ❑ Electronic Line Lcak Detector. Model: O Electronic Line Leak Detector: Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other ispecify a ui ment type and model in Section E on Page 2). Tanl 9•/ Tank ID: Erln-Tank Gauging Probe. Model: it" _1, W n- ank Gauging Prober Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: B'Pip g Sump / Trench Seasor(s). Model: , a0 j3— ReT i g Sump / Trench Sensor(s). Model: �p R-- ❑ Fil Sump Sensor(s). Model: ❑� F�ill,Sum�p Sensor(s). Model: R-Meclumical Line Leak Detector. Model: - W'IC9echanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 13 Tank Overfill / High -Level Sensor. Model: 13 Other (specify equipEnt!LReimd model in Section E on Page 2). 13 Other (specifl equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: 13 Dispenser Containment Sensor(s). Model: ,;�.E)fi'- ❑ Shear Valve(s). ❑ Shear Valve(s). El Dispenser Containment Float(s) and Chain(s).. 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: (0 Dispenser ID: 7 ❑ Dispenser Containment Sensor(s). Model: i3D R' O. 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). Dispenser ID: D.Fg: GN ❑ Dispenser Containment Sensor(s). Model: o'kD }Y ❑ Spsor(s).1 Nhmdel'.- •3Q / l3 Shear Valve(s). E3 �+�'(s)• ®v eht-'i`�/J,! N ❑Dis enser Containment Floats) and Chain(s). n me munq o, names niv,c umrcs or mspensess, copy nos corm. mmune mrormanon 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attach d a copy of the reporh (check nll Mal npplvg em Sgt_ up, hip tory re pot Technician Name (print): /✓ mmn Signature: �' Certification No.: nt o_ License. No.: /) -1 J4',i Testing Company Name:1�nr t)A 7p ST Phone No.:(Off% % 4-o ll,2__ Site ,?- Site Address: 1 1A-4=49 15 -DL-U--Batsting/Servicing: Monitoring System Certification D. Results of Testing/Servicing 1 01`3 A/W SfC CaK4,7 3TC VN l