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Y MONITORING SYSTEM CER CATION 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 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 Informatio Facility Name: Bldg.No.--V-k-- Site Address: City., *�� Zip: rJ�� Facility Contact Person: Contact Phone No.:(20q ) 4k --733 Make/Model of Monitoring S em: Date of Testing/Servicing: / J B. Inventory of Equipment Tested/Certified Check the ap2roeriate boxes to indicates tic rri ins serviced: FTank ID: Tank ID: 1 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: '1AM ❑ Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: f*9010, Mechanical line teak Detector. Model: ❑ Electronic Line LeakDetector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: �,„, ,iM✓ Tank Overfill/High-Level Sensor. Model: __ ❑ Other(specify ui t=and model in Section Eon Page 2). Other(s iLi 2quiEnt type and model in Section E on Pa a 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:J(�..21ot ❑ Mechanical Uae Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model. atvt Cl Tank Overfill/High-Level Sensor. Model: ❑ Other(s ui ment=and model in Section E on Pa a 2). ❑Other O ia 23ui=t t=and model in Section E on PaLe 2). Dispenser ID: (<®„r Dispenser ID: !74Z, ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis enser Containment Float(s)and Chain(s). Dis nser Containment Float(s)and Chain(s). ispenser ID: 3fM Dispenser ID: `14-10 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). � Shear Valve(s). Dis nser Containment Float(s)and Chain(s). ,It Dispenser Containment Float(s)and Chain(s). ispenser ID: Dispenser ID: 11+11--' ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis nser Containment Floats)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 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 repo ;(check aU dial apply): &l System set-up �1 Alarm hist ry report Technician Name(print): Signature: Certification No.: s�r`��-:J � License.No.: Testing Company Name: /jr,Af.-Ijel Phone No.:(UTU�FHD�ILrlb Site Address: 2 Date of Testing/Servicing: Pa_c 1 4if3 03:1)1 \l�utiu�;ink��>trm Crrtiliiatiun