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lrr �i�\1 l V1rII1" J 1 J 1 K ;rl l 11 1L.N 1 1 '1.11\ ' For Use By,411 Jurisdictions Within the State of Cali ornia Authority Cited: C17apter 6.7,0fth and Safety Code;Chapter 16, Division 3,W 23• California Code of Regulations 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 of this form must be provided to the tank system ownerloperator. The owner/operator must submit a cop t.d thi fo °to the local agency regulating UST systems within 30 days of test date. A. General Information FEB 2 12002 Facility Name: C ' Bldg.No.: Site Address: Wo �• !�✓�3�'.� �'e �rf� cS�� LC .,u o. + Zip: Facility Contact Person: Contact tPhotie Make/Model of Monitoring System: Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced. Tank ID: Tank ID: ❑ 1 -Tank Gauging Probe. Model: V-e T - ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: — /5 ❑ Annular Space or Vault Sensor. %Iodel: * Piping Sump/Trench Sensor(s). Model: „r$� ti'L S ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Scnsor(s). ModeL ❑ Mechanical Line Leak Detector. Model. ❑ Mechanical Line Leak Detector_ Model: lectronic Line Leak Detector. lvlodeL jS-LL t> E3eal:Electronic Line LDetector. 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). Dis enser ID: �� Dispenser 1D: 1Sispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Cd Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s).1041 ❑ Dispenser Containment Float(s) and Chain(s). user ID: '_ Dispenser ID: Ospenser Containment Sensor(s). Model: 2�—(J ❑ Dispenser Containment Sensor(s). Model: 0 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 Valvc(s). ❑Dispenscr Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the 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 Plot Plan showing the layout of monitoring equipment. For any equjiprp61.cspible of generating such reports, I have also attache copy of the report;(check all thatapply): ❑ System set-up Ld Alar history report Technician Name(print):_ iu� Zk4141 Signature: v Certification No.: tj)09©9 YS License.No.: Z Q Testing Company Name:_ebowh� Zwz Phone No.:&) 5?7- Site Address: t1a aQ �l � � ` S�aci� Date of TestingfSenicing; I/� / , Z Page I of 3 03101 Monitoring System Certification