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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, rile 23, California Cade ofAegulations This form must be used to document testing and servicing of monitoring equipment. M=jpie ared for cach MoitcLing WLzm th work. Baia form must be provided to the tank R9g=LVajiel by the technician who performs e A copy of i f system owner/oi The owner/operator must submit a copy of this form. to the local agmcy regulating UST systems within 30 days of test date_ FacilityName-- Site Address: - 0 City. Facility Contact Person: Ma` contact Phone No. . � 1 -35-0 veecte-e- rao I Date of Testing/Servicing- MakefModel of Monitoring System', — #.-6 - Tank ID; 6'1 -® F_ K I _r"". �d In -Tank Gauging Probe. JX Annular Space Or Vault Sensor. pf piping Sump / Trench Sensor(s). �26ill Sump Smsor(5). Cl Mechanical Line Leak Detector, ;d Electronic Line Leak Detector. • Tank Overfill / High -Level Sonmr. • other (!RSE_ equipment and Task ][Dz A In -Tank Gauging Probe. A=ular Space or Vault Sensor. Piping Sump / Trench Sensoi plill Sump Semor(s). U Mechanical Line Leak Detector. )21 Electronic Line LeakDetecto U Tank Overfill I High -Level Lor. 0 other (specify aqui pmenItype aand le rl FIF2T. Tlq' . Model - ,Model: DI V= D user ID, I 10� 1 Dispenser Containment Sensor(s). Model: :4 ;2016ear Valve($). 1 0 Dispenser Containment Float($) and Chain penser 10.- 3 pispenser Containment Sensor(s), Model; Shear Valve(s). N D TContainmmi Sensor(s), Model: • Dispe I • Shear V-*5)- TsaklD'. Sy/040h" /a ki -0 —1, 4in-Tank Gauging Probe. mow: MCA 0 - Pr et 6 Annular Space or Vault Sensor. Model: Z/ 0 Z- 2fflping Sump / Troxic'i Sensor(s)- Model' ME 0 'Ofill Sump SMSOT(S). Model; ec 0 Mechanical Line Leak Detector. ltto� Model! -A U'Rice"nic Line Leak Detector. r - Model: Mo IS U Tank Overfill High -Level Sensor. '0 Model: M qw �tm=mi Q w (specify e uipr� •I ank Gauging Probe. Model: • Ann Sp=e or Vault Samr. Model* zi Piping S T=ch Sensor(s). Model-. -1 Fill Sump tf a a F� Model, 13 mechanical Une Detector. ModelA U Electronic Line Leak Detector Model, E3 Tank Overfill / Ifigh-Level Sensor. Model, and model in Section E on Page 2) X DiYr' nseir containment Sensor(s). model, R -Shear Valve(s). U Disymcr Containment FIO!gs) and Uqniansar ID: 0 ser ConlWortment Sensor(s). Modd: Ul Shm S '). :t C F U Dis Qcxxser Coo ID. rW- Dis Containment Sensor(s)_ U �c j s e Modl 0 Shear Vd 8). V 0 Sh r a -Ifthe facility contains more I s "I pen sers, copy this form. Include information for every tank and dispenser at the facilitY. C. Certification - I c"fy that the equipment identified in this document was inapected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information 1 chests) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of geAMftg such repom I have SW attached a copy of the rt rt; ;rkirckAll that apply): U System set-up L3 A)" bistortVfport t' C, si Technician Name (priIW TL ak kvc 4D Signature Certification No.: License. No... Testing Company Name: 7011xvitae Leek TAE�b"Q --Phone L Site Date of Testing AddTCSS;1servicing: I ill