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moN'i.J'Rr11Ci SYSTEM C.ERT1 h__..T10_ r For Use By All Jurisdictions Within the State of Ca ji OATN' Ip,1 Aut)aoriry Cited: Chapter d.'. health and Safery Code; Chapter�6, +ljtvixa �i;l��,r,Chlifbrnia Code of Regulations This form must be used to document testing and servicing of monitoring•equipmem. A separate cer l cagon or resort must be oreaced for each monitoring system control pane!by the technician whb'periotms the wok _/ co must be provided to the tart1, system ownerioperator. The owner/operator must submit a copy of this( (the cal agency regulating UST systems within 30 days of test date. (n� A. General Information Facility Name: 51-cm IrTK _tom _ i� -_ - Bldg. No.: Site Address: 25 t< 3 .�0,ti`�u i/ C-772- 4-41 City: ,�'T��c7a --(' Zip: Facility Contact Person: !. A TT ., S �i / } Contact Phone No.:(__} Make/Model of Monitoring System fliZC /� T j0J[' Date of Testing/Servic' g: L/ ? B. Inventory, of Equipment Tested/Certified Check the appropriate'boses to indicate fie enuipurent serviced: Tt Ill. �yJ('[� -- T Z r If L_�J� 'Tank Gauging Probe. Model �ank Gauging Probe. QdeL_ Z/ L- alar Space or Vault Sensor. Model: / S,n /.fSpace or Vault Sensor. Model: Piping Sump/Trench Scnsor(s). Model: 4- L�Piping Sump i Trench Sensor(s). Model: !1'`int Z S ❑F'1 Sump Sensor(s). Model-_�- 0 F Sump Sensor(s). Model:_ U"Mechatu.-.al Line L k Detector. Model: I It ` J L 20OMechanical Line Leak Detector. :vladeL• II A"C S`/ ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: E3 Tank Overfill/High-Level Sensor- Model D Tank Overfill/High-Level Sensor. Nlodei: ❑ Other( eauipment tvu--and model in Section E on Pa 2). ❑ Other(specify E2iproent pe and model in Section E on Page 2). Tank ID: Tank M. • In-Tank Gauging Probe. Model: ❑ In-Tani;Gauging Probe. -model:_ i'-I. Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor- Model O Piping Sump/Trench Seusor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: © Fill Sump Sensor(s). Model• 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. 'Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-bevel Sensor. Model ❑ Tank Overfill/Higb-Level Sensor. Model: Q Other(specify ega!'ETELtne,ane model in Section E oa Pa e T). ❑ Other(s ifv equipment MIld model in Section E on Pae 2). Dis unser ID: % 2 ll�is�°Ser Ill: �1 `l �tenser Containment Sensor(s), Model: 5 � spcnser Containment Sensor(s). Model:`T �r�S C Shear Valve(s). Or Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chains)__ _ D—isomer ID: Dispenser ID: +��tspenser Containment Sensor(s). Model: S -4' L S D Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Contauunent T:Ioat(sl and Chaintsp. ❑ Dis u=ConminmentFoat(s)andChain(s). Dispenser.IB: DinPew'1D; ❑ Dispenser Containment Sensor(s)- Model: 0Dispensm Conmament Sensor(s). Model :lr ® Sbev lve s). U Slvahv(.•:). y DDispenser Coaminmcsu Float(s)and Chain(s). 0 DL,' enser Containment Floats)and_Chain(s). i *If the facility contains more tanks or dispensers.copy this form Include informauon for every tank and dispenser at the facility. , C. Certification-F century that the equipment identi[ied in this doeu+neu was inspeeted/seswieed in aceonlanee with the manufacturers' guidelines Attached to this Certiiect6on is information (e. uf..cturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eq meat- For any equi nt capable of generating such reports,I have also g• attached a copy or the re i f heck all that apply): System set-up M rt Technician Name(print): /'.vY Signature: Certification No.: License.No.: Testing Company Name: C�l°�� a /�(*I j �'�_+'9�— Phone No.:( Site Address: / ® t C�i 130,S9 I-AC CA I YIS-310 s I Date of Testing/Servicing: Page 1 of 3 43/01 Monitoring System Certification r r