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N NG SYSTE CE TIS' T CA /se 4v.-1ll Jurisdictions Within 1he Slate gf'Ca nia Azahority C'itecl: Chapter-6.7, Health and Safely Code; Chapter 16, Division 3, Title 23, California Code gf Regzdations This form must be used to document testing and servicing Of 111011itorina 9 1 ye =jr tification or re ort nnlst be prepared for each monitoring system control panel by the technician who pe hisform must be provided to the tank system owner/operator. The.owneperator must submit-a copy o s oral to the local agency regulating UST systems within 30 days of test date. A. General Information ' Facility Name: 00 W vt t H HAL Bldg.No.: Site Address: (rt_ —I cv bf City: Zip: Facility Contact Person: aG ( Contact Phone No.:( ) Make/Model of Monitoring System: Date of Testing/Servicing: / D. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecifie equipment inspected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: Lyy a ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 D C7 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 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: (3 Other(specify equipment ty ie and model in Section E on Pa e 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: 'l ate, ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: tYr`rU I'i ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ,, ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Surnp 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(sEecifX a ui ment type and model in Section'E'on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser 1D: )' Dispenser ID: w ❑ Dispenser Containment Sensor(s). Model: ❑ 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 1D: � Dispenser ID: 0 Dispenser Contaimneilt Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 52 ❑ Dispenser 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). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *Ifthe facility contains more tanks or dispensers,copy this=form. info. I tion f'oG every tar k and di pens rat the facility.„ x C. Certification - I certify that the equipment identified in this ocument was inspected/scr-viced�n 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 equipment capable of generating such reports,I have also attach'd a copy of the report;(check ah'that apply): ❑Syst Si" A fun history report Technician Name(print): Signature: . - - Certification No:: 06205 License.No.: /9(� /�✓�� Testing Company Narne: r D A 7Te E; Phone No.:( og ) -2�4_o l LZ Site Address: Date of Testing/Servicing: Page 1 of 03/01 Monitoring System Certification D. Results of Testing/Servicing �u