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• • MONITORING SYSTEM CERTIFICATION 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 Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be oreoared 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 form to the local agency regulating UST systems within 30 days of test date. A. General Information P,� Facility Name: �— , Bldg.No.: Site Address: C/olif(p (,�, �,� `,c , City: �o �(C� Zip: Cj 2Qt Facility Contact Person: V4 ,,.L. �.(r („ Contact Phone No.: (-fi ((,0 L—7,4.2,$r Make/Model of Monitoring System: TC.S - ; ;ser Date of Testing/Servicing:_L(-_Z- B. (-ZB. Inventory of Equipment Tested/Certilied Check the aggro2riate boxes to indicate specific equipment inspected/serviced: I TanklD: Tank ID: ni t5�\ IZ In-Tank Gauging Probe. Model: tP'CiUls 2700 ®In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ^ ►(ZO CR Annular Space or Vault Sensor. Model: c 19 Piping Sump/Trench Sensor(s). Model: ®Piping Sump/Trench Senors). Model: L.o ❑Fill Sump Sensm(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line teak Detector. Model: C9 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: y g RI — L ❑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 lD: 1, z .0, ( Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: A Annular Space or Vault Sensor. Madel: N L�y ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Seasor(s). Model: 7-air ❑Piping Sump/Trench Semor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Irak Detector. Model: ❑Electronic Line teak Detector. Model: U Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). Ll Other(specify equipment type and model in Section E on Page 2). Dispenser ID: ( 17 ( Dispenser ID: / 1j�( r__.,Qlrz ®Dispenser Containment Sensor(s). Model: Zm e EADispenser Containment Sensor(s). Madel: 19F Q Shear Valve(s). Shear Valve(s). 64 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Z kj,�1, k, -k Dispenser tD: JWDispenser Containment Sensor(s). Model: ?-or 2r ❑Dispenser Containment Senwr(s). Model: ®Shcar Valve(s). ❑Shear Valve(s). CR Dispenser Containment Floats)and Cham(s). ❑Dispenser Containment Flom(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Senwr(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)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 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 act that apply):,./ ® System set-up ®Alarm history report Technician Name(print): 4!.fir' n '.l r < ..Signature: b Certification No.: 52..1 kS S-7_ —lJT License.No.: Testing Company Name: I9e 6.4{{c (2r., Z,,, Phone No.: Testing Company Address Date of Testing/Servicing: 1/,2 S ei r Page 1 of 3 Rev(2/08)