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MONSORING SYSTEM CE TIF TI N or ULse Btu All Jurisdictions 147thin the ,Stole of California Authority Cited: Chapter 6.7, Health and Safety C'ocle; 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 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 Information Facility Name: JX Bldg. No.: Site Address: M10 1Q k}�tZP`IJ City: J Iz:i 1lel Zi p:952o3 Facility Contact Person: f/pe zd� y Contact Phone No.: ( ) Make/Model of Monitoring System: VU&C^1 004 TLS Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sneciPc eaninment inSnP tPd/eP it 1 - Tank ID: Q (_Q° _—K In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: WtCT !� Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: fd''Mechanical Line Leak Detector. Model: L -b 2 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a ui ment type and model in Section E on Pa a 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: xoo' ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dis enser ID: __ D L_ 6 L ;rDispenserContainiiientSensor(s). Model: Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(i Dispenser ID: PT_t SpT- spenser Containment Sensor(s). Model: _ Z C'6 J�KShear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Tank ID: In -Tank Gauging Probe. Model: 'Annular Space or Vault Sensor. .Piping Model: WLT ? Z Sump / Trench Sensor(s). Model: 20 ❑ Fill Sump Sensor(s). Model: g Mechanical Line Leak Detector. Model: LD 2-0012❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specifyequipment type and model in Section E on Paee 2). Dispenser [D: 1 Z- 2 d Dispenser Containment Sensor(s). Model: 2� Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(. - Dispenser I D: Dispenser l D: ❑ 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). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facil 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 thisip information is correct and a Plot Plan showing the layout of monitoring equent. For any equipm t capable of generating such reports, I have also attached a copy of the report; (check all that app/s,): 4yj%Alarm history report Technician Name (print): N1= I MMU Signatu e: Certification No.: fl I�� License. No.: Testing Company Name: i HA A TE5TPhone No.:(2_�) / g ® I Z Site Address: (a 2nd e- -, lAL-r Ij tvey►(G_ 953 Date of Testing/Servicing:015_/z3_/CPT Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03/01