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MONI. JRING SYSTEM CERTIEI _TION 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 Regulariorrs This form must be used to document testing and servicing of monitoring equipment.A saarace certiftCaiion or rcport must be prepared for each monitoring system control RVjJ by the technician who performs the work. A copy of this form must be provided to the tanl: system c,wncr/operator. The owtxr/operator must submit a copy of this form to the local agency regulating UST systems %vitbin 30 days of test date. A. Geaeral Informtion p FacilityName: SL �� Bldg,No.: Site Address: City: S�Gk1-o� t _ Zip: Facility Contact Person: 6,� Contact Phone No.: (!_) Make Model of Monitoring System e ¢T L s _3 Date of Testing/Sctvicing: 6 /OZ B. XDventory of Equipment Tested/Certified CAKk thrapero2riatt boxes to indicates ecifsc c ul ment fns ectediscn'ictd: Tank 1D: ad-t4 Tank ID: O In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: P1 Annular Space or Vault Sensor. ivi6dci: ^ O— S°n ❑ Annular Spa^e or Vault Sensor. Model: la'Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Linc Leak Detector. Modci: W Electronic Linc Leak Detector. Modcl: 0 Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Level Sensor. Model: O Other(s ecif ui ment type and model in Section E on Page 2). O Other(specify equipment t c and model in Section E on Pace Z). Tsnl ID: Tank ID: O In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Spacc or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Modcl; ❑ Fill Sump Scnsor�s). Model_ O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: O Mechanical Line Leak Detector. Model: Q Electronic Linc Lcak Detector. Model. O Electronic Linc Leak Detector. Modci: ❑ Tank O,erfill I High-Level Sensor. Model: ❑ Tank Overfill I High-Level Scnscr. Modcl: ❑ Other(specify ui ment t e and model in Section E cm Page Z). ❑ Other(specify a ui ment t c and model in Section E on Pare Z . Dispenser ID: v1 {�� Dispenser ID: O Dispenser Containmcnt Sensor(s). Model: :I Disarmer Containment Sensor(s). Model: fl Shear Valve(s) Shear Valve(s). ❑ Dispciriser Containmcnt Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain s). Dispenser ID: Dispenser 11): ❑ Dispenser Containment 5ensor(s). Model: Q Dispenser Containment Scnsor(s). Model: ❑ Shcor Valve(s). ❑ Shear Valve(s). ❑ Dispcnscr Containment Floats)and Chain(s)._ ❑ Dispenser Containment Floats and Chain(s). Dispenser 1D: _ Dispenser ID: O Dispenser Containment Scrsor(s). Model: ❑ Dispenser Containmcnt Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). 13Dispcnser Containment Float(s)and Chain(s). ❑ Disoe ser Co ntain.ment Floats and Chain(s). .If the facility contains more tanks or dispensers,Copy this form. Include information for everyrank 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 vcrIfy 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 filar apply): O System set-up O�Alarrn history report Technician Name(print):Ui¢ 4 - P—ld lLslSigaatttrey, Certification No.: 1 ? �( License.No.: 3 (� Testing Company Name: StoCktnn Service Phone No.: 20L—) 464-8 _ Sac Address: Date of TestinVServicing: eS S l b Z Page I of 3 03/01 Monitoring System Certification