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MONITORING SYSTEM CERTIFICATION 4fAY 2 4 2049 - For Use Br : l/l Jur•is(liclions Within the State of California S Awlrorihr Cifeek Chapter 6.7, Health and Sgfeh, C'o&,; ('lrapler 16, Division 3, Title 33, C'a/ifornin r/ions This form trust be used to document testing and servicing of monitoring equipment. A separate certt must be prepared for each monitoring system controlpanel by the technician who performs the work. A copy of this form must ided to the tank system owner/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 Information r Facility Name: _ Site Address: 4 oo Facility Contact Person: Make/Model of Monitoring System 1 t 1 4 1WL, B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate snecifir enteinmmt inen h Tank ID: -¢ ®e.• -C W In -Tank Gauging Probe. 01 Annular Space or Vault Sensor. N Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). 91 Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (specify a uipment type and Tank ID: _ ( [�® T- fh In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. 11 -Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). W -Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor. ❑ Other (snecifv enuinment tvne, nn(i / O -," Model: Model:'r c sa► Model: in Section E Model: Model: Model: 2OQj Model: Model 9ld 2DoUo '— Model: Model: model in Section E on Paee 2). Dispenser ID: t Y--'2_. JQ Dispenser Containment Sensor(s). Model: 8 it Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 -0 `{ ® Dispenser Containment Sensor(s). I$ Shear Valve(s). and Dispenser iD: 3 C*- t o M Dispenser Containment Sensor(s). 19 Shear Valve(s). ❑Dispenser Containment Float(s) and *If the rl Bldg. No.: City: Zip: 115zA — Contact Phone No.: { ) - .5509 50 Date of Testing/Servicing: _521( t 1 -OA ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. AL Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (soecifv enuinment tvne and Tank ID: Model: Model: Model: SWS _ - Model: - - - Model: Model: Model: model in Section Eon Paee 2). ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). _ Model. ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/ High -Level Sensor. Model• ❑ Other {specify equipment type and model in Section E on Dispenser iD: -1 q- 4B 81 Dispenser Containment Sensor(s). Model: 'Zn$ ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(sl- 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of thfreport; (check all that apply): Jul S i In ory report Technician Name (print): NL t Mo Signature: Certification No.: / ( License. No.: O 7 ' t' 11 tv Testing Compan me: 10 % A?b d 55T Phone NoA 20 ) "7 'K 47'-- O (t'L Site Address: O $� LiG/L�ti Date of Testing/Servicing: Monitoring System Certification Page I of 3 - --b3/01 D. Results of Testing/Servicing Dispenser 1D: !f -I- ( p Model: O� 2 Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Chain(s). ❑ Dispenser Containment Float(s) and Chain(: Dispenser ID: ( I '•t ("Z._ Model: C? MR Dispenser Containment Sensor(s). Model: ® Shear Valve(s). .hain(s). ❑ Dispenser Containment Floats) and Chain(: 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of thfreport; (check all that apply): Jul S i In ory report Technician Name (print): NL t Mo Signature: Certification No.: / ( License. No.: O 7 ' t' 11 tv Testing Compan me: 10 % A?b d 55T Phone NoA 20 ) "7 'K 47'-- O (t'L Site Address: O $� LiG/L�ti Date of Testing/Servicing: Monitoring System Certification Page I of 3 - --b3/01 D. Results of Testing/Servicing