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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 3,7-itle 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be 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 owner/operator. The ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GeneralInformation Facility Name.• .kf U20-�/cv- Bldg.No.: Site Address: '6'.�"� CL�d �, L� City: f es' Zip: qD Facility Contact Person: Contact Phone No.:(�) 36�T-MS Make/Model of Monitoring System: 61".) Date of Testing/Servicing: J B. Inventory of Equipment Tested/Certified �d Check the appropriate boxes to indicates serviced: Tank ID: Tank ID: ,M In-Tank Gauging Probe. Model: 144t In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: UK= Annular Space or Vault Sensor. Model: , ] Piping Sump/Trench Sensor(s). Model: J21 Piping Sump/Trench Sensor(s). Model: Z-913 ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: l Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: t=.1]r/ Electronic Line LeakrDetector. Model: ❑ Electronic Lane Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: C �ICCSt/ Tank Overfill/High-Level Sensor. Model: (3 Other(specify ui ment type and model in Section E on Page 2). ❑ Others2aift!Suipment=and model in Section E on Pa a 2). Tank IDD: tet' Tank ID• In-Tank Gauging Probe. Model: R ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 13Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: A ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Ube Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: A Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s i ui ment t and model in Section E on El Other(s i men ui t t and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: �[] Shear Valve(s). 13 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dis 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). 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 enser Containment Fldat(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. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring Vuipment. For any urpment capable of generating such reports,I have also attached a copy of the rep ;(check all dur apply): System set-up Alarm hist ry report .Technician Name(print): Signature: Certification No.: License.No.: i Testing Company Name: � .. . Phone No.:(K ) �i 40-%0?0 Site Address: Date of Testing/Servicing: 1'agc 1 orf 3 :ul Moliknrin„Scacm Certification