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b 03,'rdgW0500), 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 I&6C, rm ion Facility Name: , Bldg. No.: SiteAddress:702W—e-cA Line City: O Zip: q,5Q001 Facility Contact Person: ©W V11? Y Contact Phone No.: CG ) 95*�( — $z I A Make/Model of Monitoring System: 'ALJ �!)' 7 U Date of Testing/Servicing: 01 /K/ 03 B. Inventory of Equipment Tested/Certified f'9.....1. #t.. +. t.nvae fn inmi to -iFr an An -t incnP tPdhwryired! Tank ID: Tank ID: ;k In -Tank Gauging Probe. Model: M P,15, 44 In -Tank Gauging Probe. Model: 140, 9 Annular Space or Vault Sensor. Model: W Annular Space or Vault Sensor. Model: 14 Piping Sump / Trench Sensor(s). Model: % Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). 1$t Mechanical Line Leak Detector. Model: Model: 9600) ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: t— �— ❑ Electronic Line Leak Detector. Model: 9 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s if equipment!= and model in Section E on Pa a 2). ❑ Other (s2Eify 2qui2ment = and model in Section E on Page 2). Tank ID: Tank ID: 2k, In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: -0 Annular Space or Vault Sensor.Model: ❑ Annular Space or Vault Sensor. Model: TX Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. Model: Model: Mechanical Line 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 ment tx2e and model in Section E on Page 2). ❑ Other (sU,�ifX Squi2ment tXa. and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ADispenser 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: b Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: INE Dispenser Containment Sensor(s). Model: U ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). ❑ Dis enser 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 anyeq ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up �larm 'tory re ort Technician Name (print): OYIYI t ,r 1 Signature:C.. Certification No`�Q'^► 1 License. No.: Testing Company Name: r r y Phone No j 1� 1 2 )c - !zo Ao Site Address: 9 T7 Date of Testing/Servicing: O Page 1 of 3 03/01 Monitoring System Certification