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MONITORING SYSTEM CERTIFIC._ .TION For Use By All Jurisdictions Within tke 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. i the ;�A'sepaarate 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^IR f�,`th;� t tb ; -agency ` regulating UST systems within 30 days of test date. b ' A. General Information MAR 14 2016 Facility Name: R Site Address: City: — Facility Contact Person: Rick- Contact Phone No.: (9n) Make/Model of Monitoring System:r Oo r e� I5"3SV Date of Testing/Servicing: 1 to B. Inventory of Equipment Tested/Certified Check the g` ro riate boxes to Indicatespecific equipment inspected/serviced—.: Tank ID: sn Tank ID: CL ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: 3C1� Piping Sump/Trench Sensor(s), Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: ❑16whanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Pectronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: PULD Tank Overfill/High-Level Sensor. Model: —1 Tank Overfill/High-Level Sensor. Model:_-- Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section V on Page 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 I Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model--'Ztltk, ❑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 type and model in Section E on Page 2). Dispenser LD: — i -2 Dispenser ID: 5—Ll Dispenser Containment Sensor(s). Model: P Dispenser Containment Sensor(s). Model: ---Z�� Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chdin(s). Dispenser ID: S L Dispenser E 77-7-6 , ]Dispenser Containment Sensor(s). Model: --zr:fy Al 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 Seasor(s). Model: _z6y &Dispenser Containment Sensor(s). Model: -- ZoIr ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)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 monitoring equipment. For any egyl ment capable of generating such reports,I have also attached a copy of the report; (check all that apply): System set-up Alarm history repo Lye#u Technician Name(print): Tony Fontana n Signature: � -)J>W� Certification No.- Y.R.A23686 ICC 5289227-UT License.No.: A-846288 Testing Company Name: U.S.T. Compliance Testing Inc Phone No.:(209) 595-4489 Testing Company Address: P.O. Box 580 Ceres CA 95307 Date of Testing/Servicing: !.1�}�- UN-036 www.unidocs.ore