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MONI741ING SYSTEM CERTIFIC6I0N For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health mrd Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must he Rrepared 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 owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Inorn tion _ _ Facility Name: ( K u `t t �- 'a�� Bldg. No.: Site Address: 11-L E eo oact- City: LnW ,D�-, - Q?�[ Zip: '?��,(4 � Facility Contact Person: STELA K_L, Contact Phone No.: ( P: ) .2A'G9-04:,3(4 Make/Model of Monitoring System: f�_Q1 a(A13 X`7 �-� Date of'resting/Servicing /I a l l B. Inventory of Equipment'I'ested/Certified Check the avorouriate boxes to Indicates ectic wns eeted/serviced: Tank ID: —je Z O Tank ID: C.I ❑ In-Tank Gauging Probe. Model: , ❑ In-Tank Gauging Probe. Model: Sk Annular Space or Vault Sensor. Model: 12-0 JAn� "7 '" ¢r Annular Space or Vault Sensor. Model: r-2 G IK Piping Sump/Trench Sensor(s). Model: rJ l ' Piping Sump/Trench Sensor(s). Model: -> ❑ Fill Sump Sensor(s). Model:4- LJ Fill Sump Scnsor(s). 3;Aodel: ,Mechanical Line Leak Detector. Model: /�� Mechanical Line Leak Detector. Model:4_oN 2ac-z7). ❑ Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: © Tank Overfill I High-Level Sensor. Model T ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on['age 2). ❑ Other UeciU equipment t e and model in Section E on Page 2 . Tank ID• Tank tD• 0 In-Tank Gauging Probe. Model: - `r� ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Ll -�- Annular Space or Vault Sensor. Mode[ -' 13Piping Sump/Trench Sensor(s). Model: c ❑ Piping Sump/Trench Sensor(s). .- tViodel: ❑ Fill Sump Sensor(s). MW! ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. odel: ❑ Mechanical Line Leak Detector. Model: P Electronic Line Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Tank Ov iglu-Level Sensor. Model ❑ Tank Overfill/High-Level Sensor. Model: ❑ s ecif ui went type and model in Section E on Page 2 . Other(specify equipment t and model in Section E on Page 2). Dispenser ID: Dispenser 1D: $t Dispenser Containment Sensor(s). Model: fc.n tJ A n.) _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ❑ Dia neer Containment nont(s)and Chain(s). U Dis censer Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sen80r(s). Model: U Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Roat(s)and Chain(s). Dispenser ID: Dispenser ID: U Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensnr(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ODis enser Containment l=loat(s)and Chain(s). ❑ Dispenser Containment Floats)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 infornmtion (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 attached a copy of the report;(check 94 that apply): ❑System set-up ❑kIhistory rWort Technician Name(print): (n7TO (J2 ��ra�� it"� Signature; .� > ;*� .��,— Certification No.: Livense No.: _ =_ 7 f— 1, V Testing Company Name: A r t 0P_m t _ _ _ Phone No.:C., Site Address: ItZ:45., F k�Ptt`r . ,� ' Bate of Testing/Servicing: Page I of 3 03/01 Monitoring System Certification