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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 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 �l Facility Name: OCCJ �'�Z / Bldg.No.: Site Address: VL�l City: Zip: Facility Contact Person: Contact Phone/No.:( ) J Make/Model of Monitoring System: �GS Date of Testing/Servicing: !�/ B. Inventory of Equipment Tested/Certified S�v -' 3„�37/� S-c9 07 Check the agErogriate boxes to indicates eci6c ui ment inspected/serviced: Tr. Tank ID: k Gauging Probe. Model: �y1 ❑ Ik Tank Gauging Probe. Model:lar Space or Vault Sensor. Model: Y�� ❑ Annular Space or Vault Sensor. Model: U Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: a ❑ F Sump Sensor(s). Model: ❑fill Sump Sensor(s). Model: y - El.-Mechanical Line Leak Detector. Model: l2 d Mechanical Line Leak Detector. Model: l4t/014-W4 -- ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-beretModel: �� ❑ Tank Overfill/ sor. Model_ a7 ' w >S ❑ Qther(specify ui ment type and model in Section E on Page 2). ❑ Other OEEifj EquiEment type and model in Section E on Pae 2). Yik ID: S/ Tank ID: W 'd' -Tank Gauging Probe. Model: /°� 4 - 1 ❑ In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: ` o El 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: 9 Mechanical Line Leak Detector. Model: Ir ❑ Mechanical Line Leak Detector. Model: ❑Xectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: W Tank Overfill/ or. Model: opw b/ ® ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sEecify Squipment t and model in Section E on Pae 2). ❑ Other(specify ui ment t and model in Section E on Page 2). DisVmer ID: g Dii; rIDnser Containment Sensor(s). Model: spenser Containme Sensor(s). Model:hear Vaive(s). Shear Valve(s). ❑ Dis enser Containment Float(s)gd Chain(s). ❑ Dispenser Containment at(s)and Chain(s). i'Shear enser ID: DIMSEShear r ID: penser Containment Se r(s). Model: nser Containme tSensor(s). Model: Valve(s). Valve(s). ❑ Dis 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;n; rens' guidelines. Attached to this Certification is information (e g. ufacturers' checklis ) necessary to y that this tion is correct and a Plot Plan showing the layout of monitoring equip t. For any equip t capable of rating such rts,I have also attached a copy of the re�,Po �(c {�,¢1,�{gyp ) stem set-up la report Technician Name(pt �t�AIVGtVII(UiuIVIt1VTAL! Signature: Certification No.: 2525 W. BURBANK BLVD.BURBANKLicense.No.: Testing Company Name: ' Phone Noj-) Date of Testing/Servicing: Site Address: Page 1 of 3 03/01 Monitoring System Certification