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m MOPOORING SYSTEM CERT14ATION Fvr Use By All Jurisclicliorzs Within the,Saute gJ'C'alifornia Authorily Citecl: Chapter 6.7, I/eallh anc%Su/etv Cock,; ('hcrpter•16, Division 3, Tille 23'��' (7alijirrnia Code of'Re,!>ulwiorrs This form must be used to document testing and servicing of mon=, ?jtrk:-'Xo0PY PVS rate certification or report must bprepared for each monitoring system control panel by the technician w of this form must be provided to the tank system owner/operator. The owner/operajor must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. `g AUG 3 o2007 A. General Infor ation , Facility Name: Aa t r n t ENVIRONNIENT HEALTH Bldg.No.: Site Address: f� ! i ily tr" Zip: Facility Contact Person: c� ® _ Contact Phone No.: Make/Model of Monitoring System: ;�,&& 7 �° Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 7 Tank ID: ❑ In-Tank Gauging Probe. Model: ,7)xjn ❑ 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 Leal: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(s cify equi meat t ie and model in Section E on Pa a 2). ❑ Other(specify equipnient!ype 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 a ui ment ty a and model in Section E on Page 2). ❑ Other(sgeciEy a ui ment type and model in Section E on Pa a 2). Dispenser ID:— =V Dispenser ID: ❑ Dispenser Containment Se'nsor(s). Model: 14 /,!5 ❑ 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: ❑ 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: ❑ Dispenser Containment Sensor(s). Model: LAI ,, ❑ 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). *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 attach d a copy of tine report;(check a/1 that applt): ❑Syste et-d I rm history_report Technician Name(print): Z a J� 7,="n Signature: G �ars Certification No.: ( 0a (—}- No.:—. � '� License. Testing Company Name: Phone No.:( !�q '74—('/102• Site Address: 6-11 60c, ° t ' ': ?~ Date of Testing/Servicing: � v - Monitoring System Certification 1 01`3 03/01 A Results of Testing/Servicing