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MONITORING l$YS TEM CERTIFICATION For Use B�y All JU hlsdzctfotns Within the State of Califibmia Authority Cite& Chapter 6.7, Health and Wety tode,- 16, Division 3, rtle 23, of Begulations This form must be used to document testin.ff and s�rvirir, of rrn nlitoring cZu; :=L A -a-parate car-'Lc�='Oii oz for each moWteontrol pAnel by the technician who performs the work. A copy of this form must be provided to the tank nitgring m c system owner/operator. The owner/operator must submit a copy of this forrn to the local agency regulating UST system within 30 days of test date. Facility Name: Site Addren: Facility Contact Person: --.L% �K-k Make/Model of Monitoring System: B. Inventory of Equipmeal Ta" - U lu-Thhk Gauging Probe. Z9 Annular Space or Vault Sensor. ZPiping Sump / Trench Sensor(s). U Fill Sump Sensor(s). 0 Mcchanical Luc Lmk Detector. U Electronic Line Leak Dor. • , - MIA. 7'r-JA�$.4 Tank ED: U In -Tank Gauging Probe. 0 Annular Space or Vault Sensor. 0 Piping Sump / Trench Sensor(s). Cl Fdl Sump Sensor(s). U Mechanical Line Leak Detector. U Electronic Line LeA Detector. .7 -MI M11 =74 - I Model: Model: model: i° Model: Model: Model: C1 Dispenser ContainmentSensor(s). Model. 13 Dispenser Containment Sensor(s). Model: 0 Shear Valvc�s). Dispeimr Wt Cl Dispenser Containment Sensor(s). Model: U Shear Valve(s). UDionser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this C. Ceriffication - I cerffy that the equipmentidem guldellum Attached to this Certification Is infor correct and a Plot Plan showing the layout of monil attached a copy of the report; (check aur apply): Technician Name (print)7�� Certification No.: Monitoring System Certification Bldg. No.: City: i Contact Phone No.: (SM Date of Testing/Servicing: Tank 10: U In -Tank Gauging Probe. Model: C3 Annular Space or Vault Sensor. Model: 13 Piping Sump / Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model. E3 Tank Overfill / Ifigh-Level Sensor. Model: (3 Other 08PW* equipment t),w and model in Section E on Page Tsmk ID, 0 In -Tank Gauging Probe. Model: 13 Annular Spam or Vault Sensor. Model: U Piping Sump i Trench Sensor(s). Model: 0 Pill Sump Sensor(s). Model: U Mechanical Line Leak Detector. Model: U Electronic Lint Leak Detector. Model: C1 Tank Oveffill I 'gh-Level Sensor. Model: O Odcr,k22Ea equx Tw and model in Section E eLnLPagge tipment r- .2L. Dispenser ED: U Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). D Dismser Contninment Flo— and CNI'i Dispenser LD: 0 Dispenser Containment Sensor(s). Model; U Shear Valve(s). E3 Dispenser Containment Float(s) and Chain(s). Dispenser U): L3 Dispenser Containment Sensor(s). Model: U Shea Valve(s). 1 0 Dispenser Containment Float(s) and Chain(s). information for every tank and dispenser at the facility. Tit, 'Tv Irl L. *nufactururs' checklists) necessary to vcrffy that this fdormation if U System set-up C3 t j , Signature: License. No.: Phone No.: Date of Tcstin&/Servicing:�A�L� Pagt I of 3 03/01 2T/6'd 22t7289t7:01 96,LT-T2S-602 9NIiS31"dW03'iSn:W0aA T2:8T S002-8T-_1nf