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MONITSJNG SYSTEM CERTMCAIION For Use By All Jurisdictions Within the 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.A separate certification or report must be pnenared 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 ownedoperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name.• _ nk, Bldg.No.: Site Address:_111L (,J AAMMe/ /_1, City: J Zip:6?52179 Facility Contact Person: Contact Phone No.:(k)? )2j: . Make/Model of Monitoring System:_ar.&L T Date of Testing/Servicing: 1(2/j_T/j0_2_ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s • c ui It fns serviced: NOElectronic ID: Tank ID: -Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: t/P _ ping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Xlcsr ll Sump Sensor(s). Model: Fill Sump Sensor(s). Model: echanical Linc Leak Detector. Model: Z&_Zz20 Mechanical line Leak Detector. Model: Line UADetector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: LUL/ Tank Overfill/High-Level Sensor. Model: 4 zr-a 1 Other 42tifX 2qui2ment type and model in Section E on P e 2). t3 Other(s ui ment D=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: 0 61420 ❑ 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: M Mechanical Line Leak Detector. Model: lei ' T ❑ 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(s i ui ment=and model in Section E on Page 2). ❑ Other(sEEiLt ui ment=and model in Section E on Page 2). Dispenser ID: 11Z_ Dispenser ID: l O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). J3 Shear Valve(s). Dispenser Containment Float(s)and C "n(s). A Dis user containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: IX Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). ispenser ID: ` Ly Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dis nser 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 equipment capable of generating such reports,I have also attached a copy of the rep, ,(chemo tha apply): System set-up T Alarm report Technician Name(print): a1C/ Signature: , Certification No.: License.No.: LX__> � I Testing Company Name: % e. t�.�x��srJcJsl12 A I��:, Phone No.:( I` Y FH0—&1?,6 Site Address: („>, �, { (,,,�, Date of Test ing/Servicing: Page 1 of'3 Moniiw ink Ccriilicntiun