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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, T Isle 23, California Code of Regulations 1 This form must be used to testing and servicing of monitoring equipment. A r&arate oca9fication or n;port must be pMpared for cAdh ` nonitoring_system control panel by the WJInician who performs the work A copy of this form must be provided to the tank system ovnedoperator. The ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneraIInfor>m Facility Name. Site Address: Facility Contact Person - 1 (--. city: 5 Contact Phone No.: ( Make/Model of Monitoring System �%� .3Z 37e% Date of Testing/Servicing: / /0/- B. Inventory of Equipment Tested/Certifaed�3 ?4 - ® -5 J Check the soorooriate boxes to tndieate soecfic eauinment inspected/servier - Bldg. No.: 0 Q E ? -Z-- - Zip: 9' C Tank ID: ' In TankGauging Probe.Model: ! Tank Gauging Probe Model_O rAnnular 'Annular Space or Vault Sensor. Model: ,s Space or Vault Sensor Model: jJ .® Piping Sump /Trench Sensor(s). Model: r:Piping Sump / Trench Sensor(s). Mold: 'Z -C.# 3` ❑ Fill Sump Sensor(s). Model- -- ❑ Fill Sump Sensor(s). Model: echa' al Line Leak Detector. Model: � tom,: Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Dewaor. Model: ❑ Electronic Line Leak Detector: Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ui meat type and model in Section E on Pae 2). ❑ Other s t = and model in Section E 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 / Trench Sensor(s). Model: 7 { y �— ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Dewor. 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 (specifyf equipment a and model in Section E on Pa 2). ❑ Other (s equipment and model in Section E on Pa a 2). Di penser ID: / Z. - Dispenser ID: Dispenser Containment Scnsor(s). Model: J?, Dispenser ContaPnment Sensor(s). Model: '� hear Valve(s). 0 -Shear Valve(s). ❑ Dis nser Containment Float(s) and Chain(s). ❑ DisEMser Containment Float(s) and Chain(s). 61xmser ID: Dispenser ID: Dispenser Containment Sensor(s). .Model: ❑ Dispenser Containment Sensor(s). Model: hear Valve(s). t❑ Shear Valve(sj ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: O -"D' fe' nser Con 'nment Sensor(s). Model: 'd— 0 ❑ Dispenser Containment Sensor(s). Model: ;6- Valve(s). ❑ Shear Valve(s). C3 Dispenser Containment Flol(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 s information is correct and a Plot Plan showing the layout of monitoring urprnenL For any prnent capable generating reports, I have also attached a copy of the report; (check all that apply): stem set-up a ry re Technician Name (print): ' Signature: Certification No.: 5-70 - a — Z r& License. No.: Testing Company Name:Tt %eL :2, p Ln V %rar1%m2c%-rr- Phone No.:� Site Address:2S 2 �t�� . i?�rb rt1 "'��v Qv CV c. ,-AC CA 9( 50 Date of Testing/Servicing: Ya r 1 <S3 \lunit„ri„_ ��>irm lrrtitiiati<,n