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- a VJ VVJ,JJ r lr in rL_uLim 1 Hbt YJL MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Aurhority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 1.3. California Code of Regidatiotts This form must be used to document testitis and servicing of monitoring equipment. A_jtpdrate certification or report mutt be prepared for each monitoring system control Danel by the technician who performs the work. A copy of this form must be provided to the tank syFtem c,wncr/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems vvitbin 30 days of test date. A. Ceneral Inform tion p Facility Name. 5 OL /C.fx7i j �e—c-0 rG( Bldg.No.: Site Address: City: SfoLlt t-y t Zip: Facility Contact Person: i'i,� Je SuS cc7�i —SS-0 Phone No.: Make/Model of Monitoring System VsCda��Lor —i—LS�SJ '� Date of Testing/Servicing: _�2_/ B. Inventory of Equipment Tested/Certified Check fora ro rime boxes to indicate specific c ul ment Ins ectewserviced. Tank ID: U7 4e ti Tank ID: Z: i n-T anis Gauging Probe. lwel: ❑ In-Tank Gauging Probe. Model: Zr Annular Spacc or Vault Sensor, Model. D' O Annular Space or Vault Scnsor, Model: 2'Pipin$Sump/Trench Sensor(s). Model:6-J90— Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s), Model: O Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Modcl: O Electronic Linc Leak Detector. Modcl: ❑ Tank Overfill/Nigh-Level Sensor. Modcl: Q Tank Overfill/High-Level Scnsor. Modcl: O ether(specify ui rtunt t and model,in Section E on Pae 2 . ❑ Other(s cif c ui ment t c and model in Section E on Ptiee 2). Tani,ID: Tants ID: O In-Tank Gauging Probc. Model: O In-Tank Gauging Probe. Model: ❑ Annular Spacc or Vault Sensor. Modcl: ❑ Annular Space or Vault Scnsor. Model: ❑ Piping Sump/Trench Scnsor(s). Model: ❑ Piping Sump/Trench Sensor(s). Modcl: O Fill Sump Scnsor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Linc Leak Detector. Model: d Mechanical Line Leak Detector. Model: ❑ Electronic Line Lcak Detector. Model: ❑ Electronic Linc Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Scnsor. Modcl: O Othcr(s cif ui ment t e and model in Stenon E on Page 2), O Other(s cif a ui rnent t c and model in Section E on Pa-,e Z . Dispenser ID: 0 n V<_aJ11,4 [„c box/ 92 66L Dispenser ID: O Dispenser Containmcnt Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Fd"Shear Valvc(s), D Shear Valve(s). ❑ Dispenser Containmcnt Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID. Dispenser ID: ❑ Dispenser Containment 5ensor(s). Modcl: 0 Dispense Containment Scnsor(s). Model: O Shear Valve(s). O Shear Valve(s). O Di5pcnscr Containment Floats)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser 1D: Dispenser ID. G Dispenser Containment Scrsor(s). ::oriel: C Dispenser Containment Sensor(s). Modcl: ❑ Shear Vaivc(s), O Shear Valve(s). 13Dispcnscr Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). ,If 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' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of motsitoring equipment. For any equipment capable of gioeratiag such reports, I have also anaehed a copy of the report;(chick all(liar apply): O System set-up 0 Narm history report Technician Name(print):¢ R - W�t 104't-s Signature,; Certification No.: ZO 1 License.No.: 031&0 Testing Company Name: . Phone No.: 209 464-8U3 Site Address: Date of Tesiing/Servicing: Z J Page 1 of 3 03i0t Monitoring System Certification ` W -- c-n