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MGNIAING SYSTEM CERTIFI TON For Use By All Jurisdictions Within the State of Califonda Authority Cited: Chapter 6.7, Health and 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 be orenared for each onitorin system control panel by the technician who performs tine work. A copy of this 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 jnforation Facility Name: t F KL.LA,6 - �* ,3t)p_s Bldg, No.: Site Address: I D G, E �t ,�_t — City:_L nLL <'A Zip: 9 Facility Contact Person: ��( � Contact Phone No.: (, Make/Model of Monitoring System: "rc-"—Z,,�O I _ Date of Testing/Servicing: I 1 I?1 Z / B. Inventory of Equipment Tested/Certified Check the approgriale boxes to Indicatespecific equipment Inspected/serviced. F nk ID: `h _ __ _ 'Tank ID:In-Tank Gauging Probe. Model: � In-Tank Gauging Probe. Model:Annular Space or Vault Sensor. Model: 'V2-o Annular Space or Vault Sensor. Model:Piping Sump t Trench Sensor(s). Mode1:7 4` sPiping Sump/Trench Sensor(s). Model: p-LOlf Fill Sump Sensor(s). Model: Cl Till Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: " 2 A Mechanical Line Leak Detector. Model:4-D'Z.GOO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(specify ui ment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: Tank ID: In-Tank Gauging Probe. Model: (7 fW C- ❑ In-Tank Gauging Probe. Model: Al Annular Space or Vaull Sensor. Model: � �' � ' +:�'u� ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: ' Z��SS� ❑ Piping Sump I Trench Sensor(s). e ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mode,: 6,Mechanical Line Leak Detector. Model•_A-.6 ❑ Mechanical Line Lea ector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic L' a Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Tan 11/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ler(s eci a ui ment t e and model in Section E on Page 2). Dispenser ID:_ I yZ- _ Dispenser lD: 3 d ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Modei: A she.Valve(s). U Shear Valve(s). U Dispenser Containment Floal(s)and Chain(s). ❑ Dispenser ConlainmeM Floats and Chain(s). Dispenser li): Dispenser ID: Dispenser Containment Sensor(s). Model: I)ispenscr Containment SCtISOr(x). Model: Shear Valve(s). A Shear Valve(s). ❑ Dispenser Containment Float s)and Chain(s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID: 4-10 Dispenser ID: I t 14 \ 1 ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). 13Dispenser 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 Inrernui en is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report,(check all that apply): ❑System set-up ❑ l tom historDreport Technician Name(print): C �?�ti= ( �' ^yrs'" �'c iZ Signature: Certification No.: � License. No.: Testing Company Name: `� ` _-.- -__—_-- � � �t��r0-2i e�a„�' {�C,?��...., '�....-' Phone No.: } Site Address: i ;.� - ° r } Date of Testing/Servicing: I r� �19 /24Pf Pate I of 3 03101 Monitoring System Certification