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1�ilr , t.. .., L t MONITORING SYSTEM CERTIFICAT110 For Use By.`Ill Jurisdictions 1,17ithin the.State pf California PEJL�r r �n Authority Ciled: Chapter 6.7, Health and.Scrfeh)Code; Chapter 16, Division 3, Title 23, Ccrlifor•nia COde Of'k gu�c!/IU 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: Lol o 0D L i orJc�-' Bldg.No.: Site Address: 12-Z5CaC, z City: C1 Zip: Facility Contact Person: Contact Phone No.: ) Make/Model of Monitoring System:TS }( QQ `(' Date of Testing/Servicing: GZ / Lab- B. Inventory of Equipment Tested/Certified Check the approeriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: 91 l� In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: N A(D C�Annular Space or Vault Sensor. Model: F_/ �_ Annular Space or Vault Sensor. Model: L 5 to Piping Sump/Trench Sensor(s). Model: UL5 L/Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: C I/Mechanical Line Leal:Detector. Model: LX)20 t-3 0 Y Mechanical Line Leak Detector. Model: LLD Zx-. ❑ 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 equipment ty a and model in Section E on Pae 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). Tank ID: p L L-:.. Tank ID: sd In-Tank Gauging Probe. Model: M1 t_ - ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: F t-5 ❑ Annular Space or Vault Sensor. Model: I,-IPiping Sump/Trench Sensor(s). Model: UL.5 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Modelj,"7y c2o-0 ❑ 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 Page 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). Di penser ID: ' s Z Dispenser ID: C, Dispenser Containment Sensor(s). Model: VLA Dispenser Contaimnent Sensor(s). Model: yL. ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dip enser ID:�t � Dispenser ID: -7 4 b Dispenser Containment Sensor(s). Model: UA Dispenser Containment Sensor(s). Model: !d ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Di s enser 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). ❑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 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 it Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached it-copy of the report;(check all that appti,): ❑Sy to set ❑ Alar istor t Technician Name(print): Felix Ramirez Signature: EllCertification No.:Z Z >� 6 ` License.No.: _+ TTL#08-1740 ICC#5 °_" o. \ � -71-L_ moi; Testing Company Name: � F hone No.: ZU", ) . Site Address: Date of Testing/Servicing:I )b,4—/&8 :0 _ Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing