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MONI &ORING SYSTEM CERTIFI&ATION lse By A/l Juriscliclions 11'IN17 llze Stale of Cc zzicz Azzlhority Ciled: Chapler 6.7, Health m&Snfeo)COde; Chapler 16, Division 3, Tille 23, Califoz-nicz C e' rrfaiit�is This form must be used to document testing and servicing of monitoring equipment. 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 clays of test date. A. General Information Facility Name: /0d; h� / Bldg.No.: Site Address: iX.r I S. City: (. CA j, Zip: Facility Contact Person:_ .moi i-3 Contact Phone No.: ( ) 3.a'a . Make/Model of Monitoring System: -T --_7SQ Date of Testing/Servicing: C)& B. Inventory of Equipment Tested/Certified Check dleappropriate boxes to indicates ecific equipment ins ected/serviced: ['�U Ic ID: �;� Tank ID: fn-Tank Gauging Probe. Model: fy�/ / In-Tank Gauging Probe. Model:� 7 j An Space or Vault Sensor. Model: C1'LG> Annular Space or Vault Sensor. Model: Y710 Piping Sump/Trench Sensor(s). Model: �j- x Piping Sump/Trench Sensor(s). Model: EG Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ar Mechanical Line Leak Detector. Model: Z ?c:;1,` Mechanical Line Leak Detector. Model s% ":17''0 h9 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ty a and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: S i �inp.1 Tank ID: ,in-Tank Gauging Probe. Model: � � ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Y'd o ,!Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Za-L W'Piping Sump/Trench Sensor(s). Model: 1 LJ Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model:❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ,J>�Tank Overfill/High-Level Sensor. Model: � fl ❑ Other(s ecify a ui ment type and model in Section E on Page 2). ❑ Other(specify e ui ment tvLe and model in Section E on Page 2). KDienser ID: / f 'T M -- Dispenser ID: ispenser Containment Sensor(s). Model• �. ❑ Dispenser Containment Sensor(s). Model: ear Valve(s). ❑Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this forntln,l ide inforrnatioryfor every tank`andispener at the facility. C. Certification - 1 certify that the equipment- tide tifred in this document bras 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 flan showing the layout of monitoring eqp equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report;(check nlllhzr/zrpplt'): 0systeln se Am larhistory report Technician Name(print): . Vi i7 Signature: Certification No.: 3`'Ilf License.No.:—t1/TL .4t o'L-1211 Testing Company Name: !7 t r A r5 T" Phone No.:( -G%c/ Site Address:'_ Date of Testing/Servicin-: �7 126 Page 1 of 3 03/ol R'lonitorin"System Certification E C,;CfiTc,-tteCtF/1''_' a rvici