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'•. ,_'8 _ - MONITORING CVC CnR CATIN • • . For Use ByA11 Jurisdictions Within the State of California Xuthorht, Cited.• Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code ofRegulations This form must be used to document• testing and servicing of monitoring equipment. If more -than one monitoring system control panel is installed at the facility; 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. Instructions are printed on the back of this page. A. General Information Facility Name:- . O.l�t.�- v� Bldg. No - Site Address: IV �� I� ` 1 S�' City: � 4 / �IJ Zip: J O S FacilityContact Pelson: Contact Phone No.: �i0sZO Make/Model of Monitoring System: fix`" Date of Testing/Servicing: B. Inveintory of • Fui ment TestedlCertified � oZ 30 5_�6 q P Check the appropriate boxes to indicate specific'equipment inspeciedherviced: Tank ID:.% Tank 1D.- :In-Tank In-TankGauging Probe. Model:._i , In -Tank Gauging Probe. Model: ' Annular Space or Vault Sensor. Model: ❑,annular Space or Vault Sea=. Model: IN r Piping Sump /Trench Seasor(s� Model: ❑ P4ft Sump / Trench Seasor(s). Model• . ❑ Fill Sump Sensor(s).. Model: 5 ❑,Fill -Sump Scasor(s) "- Model: - PO Mechanical Line Leak Detector. .. Model: Mechanical Line Leak Detector; Model: ❑ Elearonic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. "Model: Tank Overfill /High -Level Sensor. Model• © zj ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Scnsor(s). . Model: ❑ bispaaser Containment Scnsor(s). Model: 04 Shear Valve(s). , jeshear valve(s). XDispenscr Containment Float(s) and Chain(s). WDispenser Containment Floats) and Chaws). ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Sectiori.Eqtr Page 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 Scnsor(s). Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model: ❑ Fill Sump Sensor(s). Model: - 13 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-Lcvel Sensor. Model: ❑ Dispenser Containment Scnsor(s). Model: ❑ Disperser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2): 1 ❑ Other (specify equipment type and model in Section E on Pago 2). C. Certification - I certify that the- equipment identified in this document was inspected/servieed.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 Site Plan showing the layout of monitoring equipment,. For any equipment - capable of generating such reports, I• have also attached a copy of the (check all that apply): S em set-up report; Ala n 1 • report. . r Technician Name (print): i� 1 CertJLic. No.: (30' SignaWre, Testing Company Name: .� • - Phone No.: 9i �`� ® ~~Y 0 J-0