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MONITORING SYSTEM CERTIFICATION For Use By rill Jurisdictions Within the State of Callfor•nia riuthorlty Cited.•- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal' ; prat Cada of ftulations 5xaa"' This form must be used to document testing and servicing of monitorin& equipment. 41-mere4ho" ere rpaenitc3 rtt#1 vont at panel is ir}stal)eri�tlt " tl}efoe;tify a -A separate certification or report must be pt'ep ra ed for each monitoring systerij control panf, 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 ;td tI* 18 C-41 Agency rogulating UST systems within 30 days of test date. Usimetlerts-a"i4itted--en hhehook of-thi. page: r. A. General Information Facility Name: Site Address: City:yCA1oV1 Facility Contact Person: Contact Plione No.: Bldg. No.. _ Gip: 01r73W - Make/Model of Monitoring System: °j'V5•-7060 Date of Testing/Servicing 1 J 3- __ B. Inventory of Equipment Tested/Certified Phonh tho 4nm•nm•into hnrec fn indiente cnerifiC enuinment tncnectedAe.rViredt: Tanit ID: ` Tail It ID: E]hi-TankGauging Probe. Model: ❑ In -Tank Ganging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/ Trench Seasor(s)• Model: ❑ Piping Sump /Trench Scasor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 14 Mechanical Line Leak Detector. Model: D ❑ 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 it& Section E on Page 2). Tank ID: Tanis ID: ❑ In -Tank Garaging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump /Trench Seasor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Linc Leak Detector, Model: 0 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'an Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser 1D.- D:❑ ElDispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valva(s). i ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 1 ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 0 Shear Valve(s). > ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser 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 Floats) 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. titan ufacturersI cheeltlists) necessary to verify that this information is correct and a Site -Plot Plan showing the layout of monitoring equipment, Trot any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑Systetn set -rap ❑Alarm ltitoty report Technician Name (print): Anthony Leivas Sigr ahue: Certification No.: b43182 License. No,: 8220969 Testing Company Name: Donlee Pump Company Phone No.: (209) 537-9396 Testing Company Address: 2825 Railroad Ave Ceres, CA. 95307 Date of Testing/Servicing: t.�. UN -036 —1/6 www.tnlltioes.org Rev. 01/17/08