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-C-o ttz.__ MONI'.. -)RING SYSTEM CERTIFILib-9E�i For Use&.411✓urisclic•lions I Nithin the.Slide of California .l athority Cited.' Chcrl.7ler 6.7, Heallh and.5gfery Code; Chapter 16, Division 3, Tille 13, CilTIH T t Tot tf ft�arlcrlions This form must be used to document testing and servicing of monitoring equipment. A se arabe certificationorre ort must be prepared for each monitoring system control panel by the technician who performs the work. AW iMMKA ► rovided to the tank system owner/operator. The.owner/operator must submit a copy of this fojt•to the UST systems within 30 days of test date. A. General Information ' �` SC I�t�d� �/ Facility Name: S 79/"K�vu� � h I e�� !S f s Bldg.No.: Site Address: 1'1 3 -;?-- v / Pf "41 City: tZ Zip: 9,5- L- Facility Contact Person:-Mu f('L 0<1S yyl l!_i Contact Phone No.:( 0 )133—",-0 Make/Model of Monitoring System: Z,,m epti Tr .1 ooa ep)— Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check thea: ro riate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: tfl/ P Tank ID: />�u /•,. ❑ In-Tank Gauging Probe. Model: a ❑ In-Tank Gaugin Probe. Model: ❑ Annular Space or Vault Sensor. Model: ;2 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 14 k j ❑ Piping Sump/Trench Sensor(s). Model: J C ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank-Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pa a 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(s)ecify eq ui ment kpe and model in Section E on Page 2). Dispenser ID: Dispenser ID: lj b 61 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: —?� �-t/ Dispenser 1D: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). h ❑ Dispenser Containment Float(s)and Chain(s). Ifthe facility contains more tanks or dispensers,copy this form. Include information for every tanJ:and dispenser at the facility. 7'�� e (J( vPy� T"u q C. Certification - I certify that the equipment identified in this ocument 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 reports,l have also attach d a copy of the report;(check all Ilia/app11): ❑Sys m set-up A Armreport Technician Name(print). 14: �, �/,'mmn Signature: t— Certification No.: 610 License.No.: 1D IIA13 Testing Company Name: O terT)A Phone No.:( D9102- Site Address: Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing