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MWITORING SS CE'*IFICATION For Use By All Jurisdictions Within the State of California Authority Cited.• Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Tft a 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 ppM for each monitoring system control panel by the technician who performs the work. A copy of this form trust be provided to the i system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within days of test date. A. General Information c„,Jo CO -� Facility -Name: Bldg. No.: Site s• UU d ? A / City: N V-'�_ Zip: Fa tact Person: ( Contact Phone No.: MabcOldodel of Monitoring System � CC 5- 5-6 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified appropriate boxes to indicatespecific ui ment Inspected/service �7 Model: P q " l C ular Space or Vault Sensor. Gauging Probe. Model: A I Space or Vault Sensor. Model: 0 Mechanical Line Leak Detector. F%6g Sump /Trench Sensor(s). Model: cP-v r ❑ ENSWup Sensor(s). Model: ❑ Other (specify equipment type an -4 Line Leak Detector. Model: LZ Atwd ❑ Ebmaic Line Leak Detector. Model: ❑ Annular Space or Vault Sensor. lI / vii Gencor. Model: y Q z / is 15,0 ❑ "fy equipment type and model in Section E on Page 22. Tallkillik ❑ Mechanical Line Leak Detector. Model: ❑ ” g Probe. Model: ❑ Tank Overfill / High -Level Sensor. ❑ AmndurSpaoe or Vault Sensor. Model: D' eraser im ❑ /Trench Sensor(s). Model: Model• L/8 d ❑• Sensor(s). Model: ❑ Uninical Line Leak Detector. Model: ❑ 13connic Line Leak Detector. Model: . 0 Madk9mmlill /High -Level Sensor.. Model: ❑ ui meat and model in Section E on Pa&S 2 . D - - il , " t Seftor(s). Model: VR 4/2. d t EjEtContainment Floats d Chains . tSens r(s).. Model: VA/ yad t Floats) and Chain(s).* Tk m: / Fd In Tank GauginProbe. Model: P q " l C ular Space or Vault Sensor. Model: iping Sump / Trench Sensor(s). Model:y 8' ❑ itl Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Modelx ,2,0 ✓ ❑ Electronic Line Leak Detector. Model: Q -Tank Overfill / Hig . _ Model: 0 D'V , ,P ❑ Other (specify equipment type an -4 model in Section E on Page 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. odel:❑ Model:- 0Other Uai S2uipment Wiv grid model in Section E on Page 2 . D' eraser im pmser(:ontainment r(s). Model• L/8 d ar Va1v.penser Containment Float(s) and-Chain(s). F rED: . `/a user Containdient Sensor(s). Model: Valve(s). Dish Dispenser TD• ❑ WwwwCbeadrunent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ )_ ❑ Shear Valve(s). OUblamurCmazinment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If "ns more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. 0offikation - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacture SOMam Attached to this Certification Is information (e g. manufacturers' chec ' ts) necessary to verify th this Informatior & Plot Plan showing the layout of monitoring eqn' ent. For any U eat le of generati uch reports, I have a 'a of the repo (dieck all that apply): System set-up ❑ story repo i T (print): Signature: ^ G Ce " ' as 0 0 ^` c� r License. No.: K) ! _. a T yName: �l fl� �� Ar�/r//J�tN PhoneNo.:� � � `�� /�c%�� Site'` "' Date of Testing/Servicing:? % y l Page 1 of 3 0310: ModbAftSyslem . rcation