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3_n, 917�;Cy� �� 1 \10NITORING SYSTEM CERTIFICATION For'Use By All Jurisdictions Within the State of California Awhorir), Cited: Chapter(;.i, Health and Safer),Code; Chapter 16, Division 3, Title 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 owner/operator most submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Inform do Facility Name: �J ak a Bldg.No.: e Site Address: �t 1 c�.� '1 L- tre e— `,� City: Zip: a' c Facility Contact Person: dw n eKContact Phone No.: (�) 3ccj'T -5 Mike/Model of Monitoring System: G2}>grw, E vy)C- Date of Testing/Servicing: / 9q/C)!:) B. Inventory of Equipment Tested/Certified Check thea ro riate boxe<to indicate s ecific. tri mens inspected/serviced: Tank ID: Tank ID: In-Tank Gauging Probe. Model: hl * In-Tank Gauging Probe. Model:M Annular Space or Vault Sensor. Model: (51 Annular Spacc or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: Fill Sump Scnsor(s). Model. '31-07 , 0 19 Fill Sump Sensor(s)t Model: C�Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Ln O Electronic Line Leak Detector. Model: _ ❑ Electronic Line.Leak Detector. Model: Ot Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Leve]Sensor. Model: V O Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Pae 2). Tank ID: Tank ID- In-Tank Gauging Probe. Model: ^ ❑ In-Tank Gauging Probe. Model: Annular Space or Vault�ensor. Model: `j ❑ Annular Space or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: tkFill Sump Sensor(s). Model: a ❑ Fill Sump Sensor(s). Mode]: .-Mechanical Line Leak Detector. Model: 1–V CkrjC_e� O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model:t 1/✓ O Tank Overfill/High-Level Sensor. Model: ❑ Other(s fv eoui ment type and model in Section E on Pa e 2). ❑ Other(s cify eouipment type and model in Section E on Pae 2). Dispenser ID:� Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containm ni Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: 1�0t, Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s).' O Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ']f the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -l 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' checklist) necessary to verify that this information.is correct.and a Plot Plan showing the layout of monitoring equipment. For any a uipmem capable of generating such reports;l have also attached a copy of the rejori;(check all that apply : System set-up Alarm history re ort Technician Name(print): A)rn I6C`S Signature: V Certification No.: Q)05 � License.No.: Q17,59) 1 Testing Company Naame1: ArmP�k� ��V\f-GV`M7dA L Phone No.:( gid � 2�� '7�f�►C'l, Site Address: 1�r7t I Cliee'1�(� ee Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring Svstem Certification