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0 r I G SYSTEMCE TI ATION r �r Use By 111 Jurisdictions Within the Slate of Ccrli ornicr At✓!/rarity C'ilecl: Chcqwer 6. 7, Heallh and Scr/cry C'ocle; C'haj.Ver 16, Division 3, Tile 23, California Code of Re�Illations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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 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. A. General Information42"i Facility Nae: . -l7 V .-� 8Y - /Bldg. No.: IV V Site Address: I 4 City:ar:RGr Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: j% I , 4 r �"/ 5 °��C Date of Testing/Servicing: 3 I�L2 VS— B. S "B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific e ui ment inspected/serviced. Tank ID: Tank ID: 7,71/7 ❑ In -Tank Gauging Probe. Model: l %-' �_ ❑ In -Tank Gauging Probe. Model ❑ Annular Space or Vault Sensor. Model: '321 3 ❑ 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: L) C ❑ Mechanical Line Leak Detector. Model: f7 U ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2). ❑Other (s ecify equipment ty a and model in Section E on Pae 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: ❑ 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: ❑ Other (specify equipment ty a and model in Section E on Pa e 2). ❑ Other (s eci equipment t e and model in Section E on Pae 2). Dispenser ID: j- — ,/ Dispenser ID: J ❑ 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 ID: Dispenser ID: 4, ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: . ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser 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). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). tt the tacutty contains more tanks or dispensers, copy this form. Include information for very tank and dispenser at thefacility, r ,,. f"�+., & /1. i! t t z. 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 attach d a copy of the report; (check all thnt crpp/v): Ll❑ S e [ fAlarm his ry report Technician Name (print): - ,i" Z2, 7,t '17 smn Signature: Certification No.: ( (0oz�j License. No.: 16) Testing Company Name: A4'0r ID_ p �,! Phone No.:� �,L��1 �" 4 j1 — Site Address: Date of Testing/Servicing: Page 1 of 3 Monitoring System Certification �[ D. Results of Testinb/Servicinu Q L �.