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R T T N ! ` _ i G SYSTEM CA®i CA i 1 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health andSafety 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 prepaied 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 FacilityName: Bldg. No.: Site Address: _ 6 54 city. l O C�L �� Zip: J Q J -Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: J4 -.Date of Testing/Servicing a 30 J B. Inveintoryof uipment Tested/Certified Check the appropriate boxes to indicate specific'equipment inspected/serviced: Tank ID.. Tank ID. k J4 In -Tank Gauging Probe. - Model: In -Tank Gauging Probe. Model: ?7v z Annular Space or Vault Sensor. Mod& ❑ --Annular Space or Vault Sensor. J' Piping Sump / Trench Sensor(s� Model: ❑ Piping Sump / Trench Scnsor(s). Mod& ❑ -Fill Sump Seasor(s). • Model: ❑. Fin -Sump Sensor(s� Model: . --� Mechanical Line Leak Detector. Model:Fr_ echanic al Lice Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- 0 Electronic Line Leak Detector. -Model: XTank Overfill / High -Level Sensor. Model• Ce tJ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Smsor(s). . Model: ❑ 2Dispenser Containment Sensor(s). Model: me Shear Valve(s). f rShear Valvc(s). Dispenser Containment Float(s) and Chain(s). WDispenser Containment Floats) and Chain(s). ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on 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 Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Lcak 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- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ -Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). - ❑ Other (specify equipment type and model in Section E on Page 2): ❑ Other (specify equipment type and model in Section E on Page, 2). . 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 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'S em set up report; Ala n 'ste report Technician Name (print): 1 Cert./L_ic. No.: ® t73� Signature: Testing Company Name: Phone No.: qi �t� ®` Q f