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rlr in rL.uum I-'HUt bL MONITORING SYSTEM C RTIFIC TIO ` For Use By All.lurfsdictfons Within tJre State of Tit Authority Cited: Chapter 6.7, Nealih unril Scrjery Code: ChapterWit i6, to State 3, Tette 13. California Code of Regulations This form must be used to docwment testing and servicing of monitoring equipment. ,& stoarat� certification or nroort mu„yrF be arc aged for each monitoring system42ntrol panel by the technician who performs the work. A copy of this form must be provided to the tank sy-tem c,%vner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A- General Facility Name: Bldg. No.: 6►4`--0.FA- Site Address: S • �v-n ® Sf City: S�LK fi°1n Zip: 4it�da- Facility Contact Person: Contact Phone No.: (,&I—) Make/Model of Monitoring System L&Or :as 1 Date of Testing/Servicing: B, Inventory of Equipment Tested/Certified Cheek the soorootiate hazes to raditate st odfie equlDment laspttt Tank ID: (1 ! A &� - _ $'In -Tank Gauging Probe. A+lodel: SI -Annular Space or Vault Sensor, Model: Q` a -Piping Sump/ Trench Sensor(s). X2jAodel: O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model:�,�7-�I� A 'Electronic Linc Leak Detector. Model: �lClGl.2� O Tank Overfill / High -Level Scnsor. Model: O Other (spec uipm►ent type and model in Section, 5 on Page 21. Tank ID: model in Section E on Pact 2). O In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Piping Sump/ Trench Sensor(s). Model: D Fill Sump Sensor($). Model: O Mechanical Linc Leak Detector. Model: 0 Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: O Other (svecifv couioment type and model in Section E on Page U. DispenserID: ' -��,JM1 hCG.U-ut Z -Dispenser Containmcnt Sensor(s). Model: i -Shear Valvc(s). O Dispenser Containmcnt Float(s) and Chain(; Dispenser ID: O Dispenser Containment Sensor($), Model: O Shear Valve(s). Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve($). QDisocnser Containment Float(s) and Chain(s). Tank ID: O In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: _ O Piping Sump / Trench Sensor(s). Model: O Fill Sump Sensor(s). Model - 13 Mechanical Line Leak Detector. Model: Q Electronic Linc Leak Detector. Model: Q Tank Overfill / Nigh -Level Scrmr. Model: 0 Other (ems equipment type and model in Section E on Pact 2). Tank ID: D In -Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensors) Modci: O Fill Sump Sensor(s). Model: d Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: Dispenser ID: ff t- ar ar pispensw Containment (Sheaf Valve($). Dispenser ID: Q Dispenser Containment Sensor(s). Model: O Shear Valve(s), O DisRSnser Containrnent Fioat(s) and Chain(s}. Dispeuser ID. G Dispenser Containment Sensor(s).Model; O Shear Valve(s). ❑ t)isnenser Containment Float(s) and Chain(s). ,If the facility contains more tanks or dispensers, copy this form. Include infottuvtion for every tank and dispenser at C. Certirleation -I Certify that the equipment identified in tbis,decumeat was Inspect iced 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 tete layout of monitoring equipment. For any equipment capable of generating such reports, l have also attacbed a cop' of the report; (check all that apply): 0 System set-upAla .t istor re ort Technician Name (print): / 2.e Wr `I i � •3 _ SignatttrG: Certification No.: '5710 —License. No.: 03 !�y Testing Company Name: Ir ik., Phone No. >4 4-8 r Site Address: �•Z / �a Sa Ft ®;.ie?r - Due of Testirt Servicin Page I or 3 -ru 43/01 Monitoring System Certification `