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i e t , MONITORING SYSTEM CERTIFICATION 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 eared 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: ir�� Bldg.No.- Site Address: City: SLA,,--s Zip:95330 30 Facility Contact Person: Contact Phone No.:(c24 )�S MakelModel of Monitoring Systeri Date of Testing/Servicing: /0//�L/IC4— B. Inventory of Equipment Tested/Certified Check the a ro riate taxes to indicate specific equipment Ins iced: Tank ID: Tank ID: In Tank Gauging Probe. Model: In Tank Gauging Probe. Model: hd Annular Space or Vault Sensor. Model: 4[A Annular Space or Vault Sensor. Model: 409 d$ Piping Sump/Trench Sensor(s). Model: ICF(- ,Q� Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: -9 Mechanical Line Leak Detector. Model: Mechanical Lane Leak Detector. Model: z4ffC ❑ Electronic Line L.eak'Detector. Model: Electronic Lane Leak Detector. Model: AP Tank Overfill/High-Level Sensor. Model:Xa Its Tank Overfill/High-Level Sensor. Model: lot/ ❑ Other(specify Equiernent=and model in Section E on Pae 2). Other 422Lif X equipment type and model in Section E on PaLe 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 lane 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 ui anent=and model in Section E on Page 2). ❑ Other(specify ui men[type and model in Section E on PaLe 2). Dispenser ID: t tz' Dispenser ID: ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and n(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: —131-111 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s). ❑ Dis22nser 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 report;(check all apply): ,�System set-up Af Alarm hist ry report Technician Name(print): S'rs�" Signature: No.: CCr 7. 5 ! Certification I\o.: 'S_.. `� • �� License.No.: t_�C3-(s/� Testing Company Name: PhoneNo.:� Site Address: K,�—Xp 4ca..,ay Ar-. Date of Testing/Servicing: 10/.jr /r3l _ 1':+,_,e 1 of 3 U:.nl �I�>nit�n in��>trm Crrtifiiati�ut