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r= LD MONfrWNG SYSTEM CE TIF T ON 9/1 State ofCalJvrnicr ocdAuthority Citecl.Chapter67, HJtX n e Chapt rnision 3, Title 23, California Code of Regulations This form must be used to document��'(�"t r ' A� C" mo t i' g equipment. A separate certification or report must be prepared for each monitoring system contrcf `i�'riel; b%,e ft 'an who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copyP'of this form to the local agency regulating UST systems within 30 clays of test date. A. General Informatione�Nv A/ ' Facility Name: G — � v,r P Site Address: - Bldg. No.:_ /9Dj �L �p • Zjp 5-t City: ®�-7-®6-1- Zip: C? 2.,:=,(,p Facility Contact Person: Contact Phone No.: ( Zj=fj46— 2.6(47 Make/Model of Monitoring Syster EF Q— TI2 LS -3cx-�' Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snerifir -.i.—# -----._ n -Tank Gauging Probe. Model. nnular Space or Vault Sensor. Model: Zp Piping Sump / Trench Sensor(s). Model: r''�Mechanical Fill Sump Sensor(s). Model: LJ Line Leak Detector. Model: 5? . MLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (spec a ui ment !Xpe and model in Section E on Pa a 2). Tank ID: --f 4! A in -Tank Gauging Probe. Model: ❑ 9nnular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: ❑ Fil) Sump Sensor(s). Model: echanical Line Leak Detector. Model: 4.719- r-( t -t> ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci a ui ment !lee and model in Section E on PaLe 2). Dols enser ID: (�6— 2 �ispenser Containment Sensor(s). Model: '2198 .i� Shear Valve(s). ❑ Dis enser Containment Float(s) and Chains) Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 17 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa a 2) Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. Model: Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Sectinn Dispenser ID: ❑ Dispenser Containment Sensoils). Model: ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). Dis enser ID: 3 �r Dispenser ID: spenser Containment Sensor(s). Model:LJDispenser Containment Sensor(s). Model:Shear Valve(s). ❑ Shear Valve(s). ❑ 2L= Containment Float(s) and Chain(s). ❑s e Dinser 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). ❑Dis enser 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 equ'p eat. For any equiDment capable of generating such reports, I have also attached a copy c the report; (check n/l that app/6): Syste set -u Alarm history report Technician Name (print): ( N iib Signature: Certification No.: License. No.: _(� Testing Company Name: 7-E��"T Phone No.:( 2®�; ?° — C' t ! 2 Site Address: P701 S. E fr ® �U �3-r Date of Testing/Servicing: -3124107- Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing 03/)1