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MON4RING SYSTEM CERTIFICTTION ko For Use Bv.'110urisdictions 1"ithin the.Stale of California Authority Cited- Chapler 6.7, Health antiS'afety Code; Chapter 16, Division 3, Title 23, Ctzlift�t•tzia(ototl e of Rc��gttlations�•7 �,, This form must be used to document testing and servicing of monitoring equipment. A separate certibt�9�pr UFE� el{ prepared for each monitoring system control panel by the technician who performs the work. A copy of thi f r i the tank system owner/operator. The owner/operator must Submit.a copy of this form to the local agency regulating USTs stems within 30 days of test(late. APR 19 A. General Inf mation Facility Name: �a, (!t A� �t ��rr WENT T rjEftM Site Address: /,�q%(J Hog City: c�"i�JL,�Tp t� Zip: Facility Contact Person: �/ Q e ,asst e Contact Phone No.:( ) Make/Model of Monitoring System: ✓Z — C;a` Tj ,3 ate of Testing/Setvicing: / / f B. Inventory of Equipment Tested/Certified Check the appro nate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Pro e. Model11 ! Ll In-Tank Gauging Probe. Model: A4 El A11111.11,11-Space or Vault Sensor. Model: '!x•3 ❑ Annular Space or Vault Sensor. Model: J 7- L] ❑ Piping Sump/Trench Sensor(s). Model: Z-0 a ❑ 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: G.,::) zood ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecif e ui ment ty a and model in Section E on Page 2). ❑ Other(specify equipment t )e and model in Section Eon Pae 2). Tank ID: �5= Tank ID: ?e— Ll e-_❑ 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: ❑ Piping Sump/Trench Sensor(s). Model: LI 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-Levet Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment ty ie and model in Section E on Pa e 2). ❑ Other(s ecif a ui nient t e and model in Section E on Page 2). Dispenser ID: ` 2 Dispenser ID: 12-Dispenser Containment Sensor(s). Model 0 Dispenser Containment Sensor(s). Model: 4qLSIiear Valve(s). hear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: YZ Dispenser ID: 0 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). Dispenser ID: he Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: L3 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser ContainmenttFloat(s)and Chain(s). ❑ DispEnser Containment Float(s)and Chain(s). *Ifthe facility contains more tanks or dispensers,copy this form. Include informationjorevery tan and disper ser attl:e Ocility. C. Certification - I certify that the equipment identified in this ocu t wa 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 attach d a copy of the report;(check all that apply): ❑Sy m s -tri ! farm I tory report Technician Name(print):� li'mmn Signature: Certification No.: 0605 License.No.: 96 Testing Company Name: r 6 j Phone No.:( UqSite Address: Date of Testing/Servicing: Page i of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing r