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MONIARING SYSTEM CERTIF&TION �L�F 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 lowagency regulating UST systems within 30 days of test date. A. General Information Facility Name: I'o'wa poId �� Bldg.No.: Site Address: b 12.,1 � �� i kre.• City: 5+oeKi l G Zip: 5.�O 7 Facility Contact Person: Tr mn Contact Phone No.: LL0� �3i�-P- Make/Model of Monitoring System: CeAer V T-S 3 SD Date of Testing/Servicing: 1 C_>/ 07 B. Inventory of Equipment Tested/Certified Check the agprogriate boxes to indicatespecific equipment inspected/serviced. Tank ID: Tam 1 G Ll ar Tank ID: Q ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ular Space or Vault Sensor. Model:dun I-JA cr rf- yd�sk•l Annular Space or Vault Sensor. Model: al +1 dro 1 i Piping Sump/Trench Sensor(s). Model:-41R ►MT 09 gc� Piping Sump/Trench Sensor(s). Model:\(/K t-A-FO9509 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: T LLD Electronic Line Leak Detector. Model: 1P LLD ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecify aqui ment Ine and model in Section E on Page 2). ❑ Other(speciL equipment a and model in Section E on Pae 2), Tank ID:-OIV� 3 \G-S� Tan ❑ In-Tank Gauging Probe. Model: ❑ In-Tank a Probe. Model: Annular Space or Vault Sensor. Model: dro_-,4,,� ❑ Annular Space or Vau r. Model: Piping Sump/Trench Sensor(s). Model:Y 2 t7 ❑ Piping Sump/Trench Sensor(s). odel: ❑ Fill Sump Sensor(s). Model: 13Fill Sump Sensor(s). El Mechanical Line Leak Detector. Model: El Mechanical Line Leak Det Model: Electronic Line Leak Detector. Model: ❑ Electronic Lin �Laaklletector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑.T,hnIF 016rr(ill/High-Level Sensor. Model: El Other s eci a ui ment a and model in Section E on Pa e 2). ea Other(sgecify equipment a and model in Section E on Pae 2 . Dispenser ID: I+ �_ Dispenser ID: 3 + ❑ Dispenser Containment Sensor(s), Model: FrA\f 0 ❑ D' penser Containment Sensor(s). Model: 1b r 1r0 ear Valve(s). ear Valve(s). Dispenser Containment Float(s)and Chain(s). is enser Containment Floats and Chain(s). Dispenser ID: !—L t"(o Dispenser ID: '7 -f"F ❑ Dispenser Containment Sensor(s). Model: R(Z1y'D ❑ Dispenser Containment Sensor(s). Model: V ear Valve(s). hear Valve(s). Dis enser Containment Floats and Chain(s). is enser Containment Float(s)and Chain(s). _Mpenser : s _�--,__. ❑ Dispenser Con`tainmen4Sensor `_.Model. ❑ Dispenser Con o odel: -.� ❑ Shea�r.V..alve(s):'--•-- ._.._.. ....._.__�.- ._. _ ❑ ShNAt ValVe s . Obis enser Containment Floats and Chain (s). ❑-'ifs enser Containment Floats and Chains . -----------^-- *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 monitoring equipment. For any equipment capable of generating such r ports,I have also attached a copy of the re ort; (check all that apply): ❑ System set-up farm histo re Technician Name(print): ]e a w";N • !J f t v� C ec o.� Signature: Certification No.: 4 2-3 L 5 �1- License.No.: 17 D`1 )2-0 Testing Company Name: £b Co,,,,, ''a-r�c 0- --s jk-,- Phone No.:(-70-7 Site Address: �,121 1 5-1oCy 0,.,F E-A' q 5,�0`1 Date of Testing/Servicing: /d/ C-)7 Page 1 of 3 03/01 Monitoring System Certification