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MONIT( mKING SYSTEM CERTIFIC For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regu(ationg, This form must be used to document testing and servicing of monitoring equipment. A wyarrinte certification or renort must*'n'reoared 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 most submit a copy of this form to the local agency regulating UST systems within 30 tt%"Rtes IEN"i Ai_ HEALTH A. General Information '"IENT FacilityName: rq cy C 1i c sl Bldg.No.: Site Address: 3-)-7Y L24C rl 731VJ1 City: 7-.Z A t y Zip: y 3 7.6 Facility Contact Person: r -S Contact Phone No.: (Zo 9 ) 63 Make/Model of Monitoring System: J reC.l r Rae r T1 S- 35-0 Date of Testing(Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate box"to indicatespecific equipment ios cted/serviced: ,'1 Tank to: /Ze l - Tank ID: )OICsal E]In=Tank Gauging obe. Model: M4`s /a'4'+L ❑In-Tank Gauging Probe. Model: A44� 12'0b Annular Space or Vault Sensor. Model: yV 9 21 Annular Space or Vault Sensor. Model. y(2`/ ®Piping Sump/Trench Semons). Model: ?66 ER Piping Sump/Trench Sensors)_ Model 705 Fill Sump Screcr(s). Model: 7 O.A Fill Sump Sensor(s). Model. ZO 6' ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak detector. Model: Qj y J4 Electronic Line Leak Detector Model: e y A 1 ❑Tank Overfill/High-level Sensor. Model: ❑yank Overfill/High-Level Sensor. Madel. ❑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: SLIQ c ro e Tank ID: ❑In-Tank Gauging Probe. Model. M43 /�+4, El In-Tank Gauging Probe. Model: aAmular Space or Vault Sensor. Madel: qoO j ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model Z c 0, ❑Piping Sump/Trench Sensot(s). Model: iQ Fill Sump Sensor(s) Model Zd4S ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector, Model: [K Electronic Line Leak Detector Model. ey 8'l ❑Electronic Line Leak Detector. Model: ❑Tank Ovehll/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Madel: ❑Other(specify equipment type and model or Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: ( - I- Dispenser ID: -7 -8 ODispenser Containment Sensons). Model: "ZOf( Dispenser Containment Sensor(e). Model: 7-0 � _ Shear Valve(s). [ Shear Valve(s) ❑Dispenser Containment Floaqs)and Chain(s)_ ❑Dispenser Containment Float(s)and Chain(s). rDispenser to: " y Dispenser ID: �- O tp Dispenser Containment Sensor(s). Model: ZO ®Dispenser Containment Sensar(s). Maki: Zd tj' [Shear Valvets). [Shear Valve(s)Dispenser Containment Flodt(s)and Chain(s). ❑Dispenser Containment floats)and Chain(s). Dispenser ID: S- o Dispenser ID: '1-\ Z Q Dispenser Containment Sensot(s). Model: Ol ®.Dispenser Containment Sensor(s)- Model Z 0 6 [2L Shear Valve(s). ES Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). -If the facility contains mote tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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 attached a copy of the report;(check all that apply): E4 Systemset-up ®Alarm history report ch Technician Name(print): 1 E U E zo u,, Signature: /� Certification No.: 8 110 Z is 3 License.No.: -7 b A g 7 t Testing Company Name: Ml/ /fit.i"Jt.,, F.C. ZNL Phone No.:(51.15 ) 9197- t y 3 7 Testing Company Address: P a /3ox Z d/ r7s.^ C4 1"63 Date of Testing/Servicing: Page t of 4 UN-036-1/4 www.unid"s.org Rev.01/17/08