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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 bg 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 ownedoperator. 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 Facility Name: N Bldg. No.: :A.)A Site Address: Ll* . ry 4, c; - City- ,,J Zip: 4; 20 Facility Contact Person: m, r c I . 6nca0lkt Contact Phone No.: ZlO SCM Make/Model of Monitoring System: _(a/i ��j,Q ffA) Date of Testing/Servicing: a-10 L J B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins serviced: Tank ID: Tank ID: 7i 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: &7zi Piping Sump / Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: .$i Mechanical Line Leak Detector. Model: a1V ,0 Mechanical Line Leak Detector. Model: 1 ❑ Electronic Line LealcDetector. Model: ❑ Electronic Line Leak Detector. Model: _ ,W Tank Overfill / High -Level Sensor. Model: C [7L/ _ 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (s i ui ment and model in Section Eon Pa e 2 . ❑ Other (s ui t and model in Section E on Pa a 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 (s Miui ment = and model in Section E on Page 2). .❑ Other (sui ment and model in Section E on Pa a 2). EE�ExDispenser 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). ❑ Diffienser Containment Float(s) and Chain(s). ispenser 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 nser Containment Fl6at(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 uipment. For any equipment capable of generating such reports, I have also attached a copy of the redo , (check all apply): System set-up f Alarm hist ry report .Technician Name (print): Signature: ; Certification No.: License. No.: Testing Company Name: < A , Phone No.: Site Address: Date of Testing/Servicing: Pa,_,c 1 of i \l�mit��rin� ��arni Crrtiliialicut