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MONITQ&NG SYSTEM CERTI " ATION Fo e By All Jurisdictions Within the State of C' is Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16,Division 3; Title 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment: If more than one monitoring system control panel is installed at the facility, 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 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. Instructions are printed on the back of this page: A. General Information Facility Name: Jej(TZe Bldg.No:: Site Address: City; Zip: Facility Contact Person E�7v-i C(, /J 6(o, Contact Phone No.: MakeJModel of Monitoring System: %�S :SS 6 Date of Testing/Servicing: fY OS B. Inventory of Equipment Tested/Certified Check the appLogriate boxes to indicate§gecific equipment ins iectedfserviced: Tank ID: 1?e?, Tank ID: AIn-Tank Gauging Probe. Model: 13 In-Tank Gauging Probe. Model: W Annular Space or Vault Sensor. Model: V o Q Annular Space or Vault Sensor. Model: W Piping Sump/Trench Sensor(s). Model: 3 Z./ ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Simp Seuor(s). Model idMechanicalLine Leak Detector. Model: 1LI ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leah Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: L'Dispeiser Containment Seawr(s). Model: 1Z,/ ❑,Dispenser Containment inment Sensor(s). Model- ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaio(s). ❑ Other ec' Equipacat a and model in Section E on Page 2). ❑ Other 2g'5 ui ment tMe,and model in Section E on Pa 2). Tank ID: Tank ID: OIn-Tank Gauging Probe. Model: Ll 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:- Q Fill Sump Sensor(s).. Model: O Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model ❑Mechanical Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/high-Level Sensor. Model:' ❑Tank Overfill/Iligh-Level Sensor. Model: 11 Dispenser Containment Sensor(s). Model: U Dispenser Containment Seiasor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Other ec ui m®t a and model in Section E-on Pa 2 . ❑ Other ec'�meat a and model in SectionE on Pa 2. 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) netzssary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(check all that apply): ❑System set-up report; je ❑Alarm history report Technician Name(print): �O/IHJT! /J Cert./Lic.No.: 4945 6-o5-alta kure Testing Company Name: �C �%g� Phone No.: Sia 7Sf/P7�y