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MONITORING SYSTEM CERTMCATIOIP For Use By All Jurisdictions Within the State of Cakyornia Authority Cited: Chapter 67, Health and Safety Code; Chapter 16. Division 3; ?file 23, California Code of Regulations This foam must be used to document testing and servicing of monitoring equipment. A separate oatification or report must bg Lsneoamd & each monitoring control pard by the technician who performs the work. A co0y of this foam must be provided to the tank system oWWdoperator. The ownedopeaator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Wormation Facility Name: Y f K .3 j Z Bldg. No ---2_ Site Address: 3 S s-- �. -, ,/ �,,,,y �� .�... City: 'r'd Facility Contact Person: Contact Phone Noy ( t Make/Modd of Monitoring System: Date of Testing/Servicing.6 e 2 a B. Inventory of Equipment Tested/Certified " Check thea ' to boxes to indicate serviced: Tank ID: In Tank Gauging Probe. Model: Tank ID: �F T 43 In Tank Gauging ✓ �+t.a / Annular Space or Vault Sensor. Modell _ Probe. Model: Annular Spee or Vault Sensor. Model: ❑ Piping Sump /Trench Setrsot(s). Mold: i/Iz C1 Piping Sump /Trench Sensor(s). Model f3 ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: AM Mechanical Line Leak Detector: Model E i e r ,g L 0 .Ei-Mechaaical Line Leak Detector. ❑" Electronic Lane Leak Detector. Model: ❑ Electronic Line Leak DOAX*M Model: a --Tank Overfill / tgS sor. Model: A"Ae—e, Overfill / odek —Ac G ( ui t and model in Section E on Pa a 2). ❑ Other ( ai t and model in Section E on Pa 2). ID: TankID: rer Tank Gauging Probe. Model vi ) ❑ In -Tank Gauging Prebe. Model:nular Space or Vault Sensor. Model• t//L t/ t q ❑ Annrilar Space or Vault Sensor. Modek ing Sump / Trench Sensor(s). Model: ✓/2 Er; ❑ Piping Sump / Trench Sensot(s). Model: ❑ Fill Sninp Sensor(s). Model- ❑ Fill Sump Sensor(s). Model AtrMechanical Line Leak Detector. Model-, r -AL 111,e At fS ❑ .Mechanical Line Leak Detector. Model: '0 Electronic Line Leak Detector. Model: ❑ Elccmonie Lane Leak Detector- Model: ank Overfill /High Model: 4?!sz. e --�j ❑ Tank Overfill / H'igh-L cvd tensa. Model: ❑ Other (sPcciD=ui2mcnt = and model in Section E on PaLc 2). Cl Other (sE= Muipment type and model in Section E on PaLe 2). Dispenser ID: Dispenser ID: 3 AR Dispenser Containment r(s). Model: t/r''�07ait 0Dispenser Containment Sensor(s).-Model: 1/ JShear valve(s). -6 Shear valve(s). ❑ DiseaLx Containment Float(s) andChain(s) . ❑ Dispenser Containment Floc ) and Chain(s). Dispenser ID: f Dispenser ID: Dispenser Containment Sensor(s). Model: i/A? cd'• C1 Dispenser Containmea Sensor(s). Model: Shear Valve(s). -In Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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). CIDiSM1W Containment Flofi(;:) and Chain(s). ❑ Dismser Containment Float s) and Cbain(s). off the facility contains more tanks or dispensers, copy this form. Include information for every Link 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable ofen g ting such reports, I have also attached a copy of the reporU,4check all that apply): stem set-up AR-Alamphisrbry t't •" Technician Name (print): I . S31ZL- , A rJ Signature: - cation No.:- tJ 7S cj license. No.: ®ate ' /Ko�- se� Testing Company. Name:Tt- Phone NoAS _)--gj"LL(? - -10 A 0 Site Address:25L:t;1) Qiir .,k CA 9t5015' Date of Testing/Servicing. //�/� t - Pag-v 1 4 3 mist