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F9 FCS �A [ `V'�� D, i MONIPRING- SYSTEM CERTIn AVON For Use By All Jurisdictions Within the State o03 f California �� Authority Cited: Chapter 6.7, Ilealth and Safety Code; Chapter 16, Division 3, Title 23, California Co%Wq ffl'1t T HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or ren v� 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 Inf Information Facility Name: U i)r 3� j� Bldg. No.: Site Address: 290 .41 es!, R& jam_ City:liu�e Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: hg,-c cf E /M C Date of TestinglServicing: B. Inventory of Equipment Tested/Certified Check the appropitme boxei to f idieate sneelfic eauinment tnsneetedAervicedt Tank ID: O�ZLi i TanID: Z-'cet F %Z -Tank Gauging Probe. Model: s IZZ71 )let ` L'3'1"n.Tank Gauging Probe, Model: 066 d ','7G �Erj nular Space or Vault Sensor. Model: 0 - "12 6 d6nnular Space or Vault Sensor. Model: 07,5"790 p`Piping Sump / Trench Sensor(s). Model: 621R[�'�L EKping Sump / Trench Sensor(s). Model: d 7W 7kJ - 2 C3 ❑ Fill Sump Sensor(s). i hechan:cat Line 1,ak Deeector. Model: _ Model:? (� `l%� ❑ Pill Sump Sensor(s). iff"Mechanical Line Leak Detector. Model: 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 eci cq2ipmwent, and model in Section E on PaLe 2). ❑ Other (sped equipment t and model in Section E on Pae 2). TF T ID: C'' E . Tank ID: Tank Gauging Probe. Model: i` 6 ` 3 74) ❑ In -Tank Gauging Probe. Model: Space or Vault Sensor. Model: �,� ` ❑ Annular Space or Vault Sensor. Model: 6r Piping Sump / Trench Sensor(s). Model: t 15 V 1 510 - , ❑ Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: _ ❑ Fill Sump Se'nsor(s). Model: WMechanical Lute Leak Detector. Model: (e U ❑ Mechanical Line Leak D&ector. 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 eci ui mint IXE and model in Section E on Pa a 2). ❑ Other (specify equipment and model in Section E on Pae 2). Dispenser ID: Dispenser ID: L7 R"tspenser Containment Sensor(s). Model: ❑ _Pispenser Containment Sensors). Model: Aff hear Valve(s). U'Jwar Valves). Disg5nser Containment Float(s) and Chain(s). -WDispenser Containment Floats) and Chain(s}. Dispenser ID: Dispenser ID: ;!6 8 Q pispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: &$hear Valvc(s). Valve(s). Xbhear is nser Containment Float(s) and Chain(s). Dis nser Containment Float(s) and Chain(s). Dispenser ID - Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: EI' hear V-ive(s). ❑ Shear Valve(s). —6s nser Containment Float(s) and Chain(s). ❑ Dis nser Containment Float(s) and Chain(s). 'lf 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 inspeeted/servieed in accordanee 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 oenerating such reports, I have also attached a copy of the repoA(c eck ajL xh ply): ❑ System set-up ® istor r o Technician Name (print): ` r P, Signature: Certification No.: % t� License. No.: Testing Company Name: � � t " j tic j .7ce Phone No.: Site Address: ,,,�' i ( �J y i � _�S i 3 -je f `( Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification