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MONITCONG SYSTEM CERTMCAION For Use,ByAll Jurisdictions Within the State of California Authority Cited Chapter 6.Z Health and Safety Code;Chapter 16,Division 3,Tale 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or Ewgrt 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 ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneralInformatio,�-- Facility Name it 3 Bldg.No.. Site Address: $' /l2/, C L v City: I 1&r— Zip: Facility Contact Person: Contact Phone No.:(� Make/Model of Monitoring System:�r( � S✓ Date of Testing/Servicing- S~/ l,3/6 7 B. Inventory of Equipment Tested/Certified , Check thea roriate boxes to indicate .u meatserviced: FTank ID: • �-7 T, ID: / In-Tank Gauging Probe. Model: j/1Z M A/" ! l�'1 In-Tank Ganging Probe. Model: 3 - _ Annular Space or Vault Sensor. Model: ✓/C k o QF Annular Space or Vault Sensor. Model:�LZ d- 'ping Sump/Trench Sensor(s). Model: V/t o Piping Sump/Trench Sensor(s). Model• 1/I^ ?y� ❑ Fill Sump Sensor(s). Moder: ❑Fill Sump Sensor(s). Model: Mechanical Line Leak Detector Model: e--)A 4 pa Mechanical line Leak Detector. Model'L/Jac>cy ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Oveifill/High sot Model:e ISG/ /U f Tank Overfill J r. Model: w" VI ZJ ❑ Other(s ui ment=and model in Section E on Page 2). ❑Other(s222jfj equi2=t type and model.in Section E on Page 2). Tank ID: l Tank ID: In-Tank Gauging Probe. Model: Vn mQ / ❑ In-Tank Gauging Probe. Model: Annular Spacc or Vault Sensor. Model �_ Annular Space or Vault Sensor. Model: rZ !Z07 ❑ Piping Sump/Trench Sensor(s). Mo ] Piping Sump/Trench Scnsot(s). Model: ❑ Filla$ump Sensor(s). Model: ❑ Fill Sump Se isor(s). Model: a Mechanical Linc Leak Detector. Model: r✓ f y/'l>7 ❑ Mechanical 11he Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: A Tank Overfill/ r. Model:A7�r e-el 4 I ❑Tank Overfill I High-Level Sensor. Model: ❑ Other(s ui ment d model in Section E on PaLc 2). ❑ Other(s ui t t and model in Section E on Pa&e 2). FCD' er ID: Z-- Dispenser ID: ispenserContainment r(s). Model: a l Dispenser Containment sor(s). Model: Vg=Shear Valve(s). r,i -Shear Valve(s). Dis ser Containment Float(s) dChain(s). ❑ Dis ser Containment Flo (s)and Chain(s). spenser ID: S Disp"lbser ID: Dispenser Containment Senso s). Model: ti A -7c;?/ Dispenser Containment sor(s). Model: WL. 3.�' Shear Valve(s). hear 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). CIDispenser Containment Flog(;)and Chain(s). ❑ Dis2Mser Containment Floats 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 eqTpment capable of geWrating such reports,I have also attached a copy of the report„(check all that apply): System set-up UWarm hist eport Technician Name(print): 1. Cy2LOR A rJ Signature: Cd4fication No.: f Y2 -VQ 75 License.No.: 0;2 �- Testing Company Name:MSQ_c: 'e PhoneNo.:(ax-ea-) F-, 7 -l0OL0 Site Address:25 2�t;� i r��,`C \u et� QJrbe'IV- e A 9t SyS Date of Testing/Servicing: /13 Page i (&3 ui:u1 \ZaniUu-it�_��Sirnl C.•criilicatiun