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y � AlONII ORING SYSTEM CERTIFICATIOiv For Use By All Jurisdictions Within the State of Californiq�; 1 t Autho C- tew t er 6.7, health and Safery Code; Chaprer M, Division 3, Tida_V, California Code•o�`Re ,.ts This form must bedbgitt%nt testing and servicing of monitoring equipment.,A separate t: r ust b ore ed „�rv, for each M' 4n S`s 66-6 oipanel by the technician who performs the work.. A copy of the � system own tx e owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General InfO lion Facility Name: '`le -121 ('lj�CG' I fi((f C S- e r Llf(f e Bldg. NO.: _ g Site Address: City:L> J t zip: I Facility Contact Person: /Z Pijz_-)yA 1-1-A Contact Phone No.: (____) 3C ~ ` kc f Make/Model of Monitoring System 5 '- L be: fC -Fill orl Date of Testing/Servicing: i/2bb c- � B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment hwpected/servieed: Tank ID: Tank ID: l'Z I /—,7 ❑Tank Gauging Prole. Model: +'fin -Tank Gauging Probe. ?Model: Annular Space or Vault Sensor. Model: 3' `,itt . ��'t t. al"ular Space or Vault Sensor_ .-Model YPiping Sump / Trench Sensor(s). Model: ? S '1,2_0 ,0c0? Uk fltping Sump / Trench Sensor(s). Model: _A GA4) S1.2 C14X X0 ❑ yill Sump Sensor(s). Model: O }rill Sump Sensor(s). .Model: EbAl Mechanical Lme Leas Detector. Model: 11� ` e2,` O/Mechauical Line Leak Detector. :rlodei: / / L 73 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. --Model: ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill f High -Level Sensor. Model: El Other (s i meat and model in Section E on Pae 2). ElO[her (stick' i nt and model in Section E on Page 2). Tank ID: Tank ID: S e L O In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: 2' nular Space or Vault Sensor_ Model: ti J i It t '(60C ❑ Annular Space or Vault Sensor. Model P40, :j -,F .AeZl & Piping Sump /Trench Sensor(s). Model: PA tj',JV13�4;� ❑ Piping Sump / Trench Sensor(s). Model: P14 L•' 6'00,2 CC ❑� Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model- Mechanical Line Leak Detector. Model: L S 1C ❑ Mechanical Line Leak Detector. _-Model: ❑ Electronic Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model- ❑ Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model• ❑ Other (s t and model in Section Eon Pa a 2). ❑ Other ( i mens pT5 and model in Section E on P 2). Dispenser ID: `'l' -Z. Dispenser IDVic( ❑ Dispenser Containment Sensor(s). Model: ❑ penser Containment Sensor(s). -Model: ��iear Valve(s). �j ar Valve(s). is nser Containment Float(s) and Chain(s). er Containment Float(s) and Chain(s). Dispenser ID: '+ - Dispenser ID: ❑ Dis1010penser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: RE�" hear Valve(s). C�'Si�ear Valve(s). Dis nser Containment Float(s) and Chain(s). i!EELSE Containment Float(s) and Chain(s). Dispenser ID: 3Dispenser- ID; O ippenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: '!Q,e•n v�tve st. 0- /.tear Val %• (-_). 9_'�spenser Containment Floatfs) and Chain(s). Dispenser Containment Float(s) and Chain(s). * f the facility contains more tanks or dispensers, copy this form Include information for every tank and dispenser at the facility. C. Certification -I eertify that the equipment identified in" document was inspee-ted/servieed in ac:cofdanee wish the manufaetturers' guidelines. Attached to this Certification is information (e.;, 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; Fh k allt ap 1 ): 0 System set-up 0 Alar��ry re _ t Technician Name (print): +� J'tl�f Signature: Certification No.: f� / Z License. No_: p Testing Company Name: ( ✓fit 1s'1�l ' Ci .`� 0 rtt �-� r - �t7 Phone No.: � 5CC) d � o " I y/ 1y7 Site .Address: C-, 4f `i5 Yl 3 A!Aate of Testing/Servicing: Page I of 3 03/01 Monitoring System Certification