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MONITORING SYSTEM CERTIFICATION 2 ,) Tor Uve By.111 Jurisdictions II"ithin the State of California d,�l J r1 uthorih,Cited: C'hapier 6.7, Health and.ScAety Code; Chapter/6, Division 3, Title 23, California Coc .F f(f �r rrl�Svrs 11 1i a CC�sVV l r`f f This form must be used to document testing and servicing of monitoring equipment. A separate certification `orr� prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be pro r l 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 Facility Name: K ' ��, ). i ,",r.,, , ,., Bldg.No.: �( �� ` t G Site Address: �:� -..;��k' City: �`� ) = �N'": Zip:11 15 r,. Facility Contact Person:��1�(� Contact Phone No.:(20- 09(1 31� 1 3 Make/Model of Monitoring System:V f-C dk' \- �<o " -TI-5,24"� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates ecific a ui ment ins ected/serviced: T. Ic ID: t _ Tank ID: In-Tank Gauging Probe. Model: C� ( � ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ �� ❑ Annular Space or Vault Sensor. Model: Piping Sump/ or Sensor(s). Model: 2015 ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: EJ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: U.Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equipment ty e and model in Section E on Pa e 2). ❑ Other(specify a ui ment type and model in Section E on Pae 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 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 equipment t pe and model in Section E on Page 2). ❑ Other(s ecify equipment t e and model in Section E on Pae 2). Dispenser ID: 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). ❑ 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 Containnent 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 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 repot;(check all that apply): ❑Sy em�:Set- LJ Alarm history ' t Technician Name(print): Felix Ramirez Signature: I 3', n_P TTL#08-1740 ICC#5273934-UT Certification No.: f k License.No.: r� _ t Testing Company Name: f E.' �- . �` r Phone No Site Address:' z LArF,r` k Date of Testing/Servicing:jj 7'� } t = Page 1 of 3 03/01 Monitoring System Certification D. Results of Testing/Servicing