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MONITORING SYSTEM CERTIFICC. .PION 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 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. A. General Information Facility Name: ,A P-cl) �� Bldg.No.: Site Address: 6100 A1, 14W��29 City: c4uy,d Zip: Facility Contact Person: Contact Phone No.: y Make/Model of Monitoring System: U r X 17 r/YZ —/2L+6 1 ,5-3SO Date of Testing/Servicing: J 1-3110Z B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: - � Tank ID: ME-ibt--11 E) In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4 Annular Space or Vault Sensor. Model: �0,4-r Piping Sump/Trench Sensor(s). Mo( 1aC Piping Sump/Trench Sensor(s). Model: a"�T ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: a 4114-00 4_'5' X Mechanical Line Leak Detector. Model: 44/-oc 6-<S- • 5❑ 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 type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 54AUS - Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: 151.°Annular Space or Vault Sensor. Model: -jC--A_arW ❑ Annular Space or Vault Sensor. Model: 'Piping Sump/Trench Sensor(s). Model: -i LAoge!r ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: V,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/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). Dispenser ID: / f 2 Dispenser ID: "') `K Dispenser Containment Sensor(s). Model: (VA44 $C Dispenser Containment Sensor(s). Model: Lvt�T �1 Shear Valve(s). $f Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 -f y Dispenser ID: 14Dispenser Containment Sensor(s). Model: Lr{,&44 ❑ Dispenser Containment Sensor(s). Model: W Shear Valve(s). I ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 Ce Dispenser ID: 1�i Dispenser Containment Sensor(s). Model:r"06-T Cl 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). *Ifthe,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 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): ❑ Syste et-up Al rm Distory report Technician Name(print): Z:S iA4 ES J 11 Signature: Certification No.: e, z_1�7_q ./Or License.No.: 90 GM 1-12. Testing Company Name: RICO= "Q 1�4g JAZ Phone No.:�(a�,! )_-3qA-:R-6 g-7 Site Address: re/CSO Al, - 99, SIR C.k-7y SCJ Date of Testing/Servicing:, /-31-d L Page 1 of 3 03/01 Monitoring System Certification