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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the.Stute of CaU%61.110 .-I whorily Cited: Chapter 6.7, Health and Safety Cocle;Chapter 16 Dh1i5i017 3, Till,23, California Cole 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 clays of test date. A. General Information I n Q Bldg.No.: Facility Name: '"1 Site Address: )�I _ r� U City:f 'mlC,� +�# gZip: ') Z� Facility Contact Person: �t�XliGs Contact Phone No.:(��))1Zip: Make/Model of Monitoring System:�Q-Pc)Q-f �' Date of Testing/Servicing:(�1�/na B. Inventory of Equipment Tested/Certified Cheek the a>pro rime boxes to indicate s iecific a ui meat ins ected/sell,icc( l: Tank 1D: T—) LF Tank 11): In-Tank Gauging Probe. Model:_ NI�4C� �_____ Xln-Tank Gauging Probe. Model: ! � 1Annular Space or Vault Sensor. Model:_ t4 )- ; nnular Space or Vault Sensor. Model: 14W !J Piping Sump/Trench Sensor(s). Model:__ ZU� Piping Sump/Trench Sensor(s). Model: Zt�, ❑ Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: _ ❑ Mechanical Line Leal:Detector. Model: L-1) 'Loo•J fd Mechanical Line Leak Detector. Model: De --k3.l. e ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank.Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment ty ie and model in Section E on Page 2). ❑ Other(s ecif y equipment ty ie and model in Section E on Page 2). Tank ID: 9 { Tank ID: �In-Tank Gauging Probe. Model: Nl to C, (__ ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: tf ZD L) Annular Space or Vault Sensor. ]Model: jd"Piping Sump/Trench Sensor(s). Model: 2 Cab ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ---- LJ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: 2 —_ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:_- ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify e ui meat q'pe and model in Section Eon Page 2). ❑ Other(s ecifv e ui)ment ty e anti model in Section E on Page 2). Dispenser ID: 17 z _ Dispenser ID: > - ----- ❑ Dispenser Containment Sensor(s). Model: ____ ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). !Lar Shear Valve(s). Dis)enser Containment Float(s)and Chain(s). IWispeilser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: f AC; if � ---- —- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contatnment Sensor(-,). Model: p -- --- ( Shea-Valve(-,). 0 Shear Valve(s). Dispenser Containment Floatds)and Chain(-,). Dis enser Containment Float(s)and Chain(-,). Dispenser ID: Dispenser ID: - --- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(-,). ❑Dis enser Containment Floats). and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 11'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' cheeldists) necessary to verify that this information is correct and at 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 applt'): ❑S ste i set-up ❑Alarm history report Technician Name(print): Felix Ran irez Signatul•e: Certification No.— License.No.• UTTL#08-1740 ICC#5273934-UT Testing Company Name: ��b r� � T Phone No.:(��)7�4 " b l E Z Site Address:'Jo �.a\31� �� U. l _ Date of Testing/Servicing /Z 7 "j: Page I of 03/01 Monitoring System Certification D. Results of Testing/Servicing