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MO T O G SYSTEM �.T' CECATION r Use By,111 Jurisdictions Within the State o forma Authority Cited- Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Yitle 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment A separat t be prenared for each monitoringsystem control panel by the technician who performs the work. A copy ot to the-tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. J 19 2003 A. General Infox=atio Facility Name: Site Address: ` CityLCA( Z' R p Facility Contact Penson:. V' Contact Phone No.: 0 t ) Make/Model of Monitoring System W ® Date of Testing/Servicing: B. Inventory of Equipment Tested/Certined Cheat the appropriate boxes to indi to ecific i went i ected/serviced: Tank ID: ! Tank ID: -la-Tank Gauging Probe Model: rl In-Tank Gauging Probe. Model: Annular.Space or Vault Sensor.. Model: r J ' ault Sensor. Model: iping Sump/Trench Sensor(s). Model: C3Pi g Sump Sr/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ MechaNEal Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: ❑ Electroni ine Leak Detector. Model: 3.Tank Overfill/High-Level Sensor. Model: , ❑ Tank Ov /High level Sensor. Model: ❑ Other( e ' 'uSent a and model in Section E on Page 2). C1 Other ui t 5,Te and model in Sq&ion E on Page 2). ID: Tank ID: ❑ -Tank Gauging Probe Madel: ❑ In-Task Gauging lie Mod ❑ An lar Space or Vault Sensor. Model: ❑ Annular Space or ult Sensor. M el: ❑ Piping ump/Trench Sensor(s). Model: ❑ Piping Sump/Tren ensor(s). oriel: ❑.Fill Sump ensor(s). Model: C3 Fill Sump Sensor(s). oriel: ❑ Mechanical'hine Leak Detector. Model: ❑ Mechanical Line Leak D or. Model: ❑ Electronic Lin�l..eak Detector. Model: ❑ Electronic Line Leak Dete r. Model: ❑ Tank Overfill/Hah-Leve!Sensor. Model: 13Tank Over /High-Level S sor. Model: ❑ Other(sped uip�nent type and model in S an Eon Pa a 2). ❑ Other(specify equipm=nt e d model in Section E on Pa 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Se r(s). M el: ❑ Dispenser Con tai Sensor(s� %Mylodel: ❑ Shear Valve(s). ❑ Shear Valves} 0 Dis eraser Containment Floats Chain s). ❑ Dispenser Con anent Flo s)and (s). Dispenser ID: Dispenser ID: ❑ Dispenser Con ensor(s). Mo l: ❑ Dispenser ntainment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear V s). ❑ Di ser t F1oat(s)and Chain(s). ❑ Di er Containment F122t(s)and Chain(s). DisPe Disp ID: ❑ D' enser Containment Sensor(s). Model: ❑ ispen,er Containment Sensor(s). Model: hear Val�ve(s). Shear Valve(s). 1666penser Containment Floa s)and Chain(s). Dispenser Containment F12at(s and Chains. *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 (eg. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any ui Sent capable of generating such reports,I have also attached a copy of the eck 4N thatr ► ly: System set-up report. Technician.Name(print):_ , L , Signature: Certification No. License.No. os l y a G1Z Testis C Name 0 Testing Amy Phone No.'GS�� aO 5r``t 6-1-8 Site Address- ® ® Date of Testing/Servicing: Page I of 3 03/01 Monitoring System Certification