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MONITORING SYSTEM CEWfIFICATION For Use By,411 Jurisdictions Within the State of Crrltfornia Authority Cited:- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, Califo AW,, Code of Regillations This form must be used to document testing and servicing of monitoring equipment. if mere--t)rfln�t3a rRottiterf+��syetiteil1utel is istafleti iii w.., 9ie-fae&j,-a-A separate certification or report most lie plepared for each monitoring system control nanj by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. The owner/operator must submit a copy of this fore. o tl ° ca ncy regulating UST systems within 30 days of test date,—FHst+t+otierre panted on t}ts ��nck of tHi image' '`' A. General Information - Facility Name: " j�i� !moi- Bldg. No.: " Site Address: 7tei1 4{ffra�r� City:SCO`ioY1 Zip: X5320 Facility Contact Person: Contact Phone No.: _ Make/Model of Monitoring System: I'l,15-?60 Date of Testing/Servicing j -- B. Inventory of Equipment Tested/Certified .1.- -----1-- 1-F I. n..nn in Iun}n a nninn a r. i..,I.PV{ IIIQIIPPrPIt ICPRIOP PItL! LIIGI:II {Ili: n I Ic V Ia In [.. r,vna� •v .•.... wr.av v s..�..... r. ....... v....... .--.-_---_ . ___..y Tank ID: Vie ']tank ID: Q 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: 0 Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: Mechanical Line Leak Detector. Model: D La ❑ 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 (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: ❑ Pill Sump Sensor(s). Model: ❑ Mechanical Lino Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Fleetronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Sec(ion E on Page 2). Dispenser ID:' Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Seasor(s). Modal: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s), ❑ Dispenser Containment Flont(s) and Chain(s). Dispenser ID: Dispenser ID: [] Dispenser Con€ainment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: [] Shear Valve(s). L] Shear Valve(s). Q Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Eloat(s) and Chain(s). Dispenser- ID: Dispenses Ill: Q Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Q Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Cbnin(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification -1 certify that the equipment identified in this tlocntnemt 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 n S.iWPlot Plan showing the layout of nioulto•ing equipment, For any equi�iistent capable of generating such reports, I have also attached a copy of the report; (cheek all that app.}): ❑ System Set-up Alarm III tory report Technician Naine (print): Anthony Letyas Sigature: Certification No.; b43182 � License. No.:' 8220961 Testing Company Name: Doniee Pump Company Phone No.: �209�537-9396 Testing Company Address: 2£325 Railroad Ave Cores CA. 95307 Date of Testing/Servicing: __�.� S %;Z- [Jit -036 --1/6 lv5YwanlidOcs.org Rev. 01/17/09