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MONITORING SYSTEM CERTIFICATION For Use Be All ,Jurivilictions Within the .Viote of ('atifinviiu Authority Cited Chapter 6.7, Health and Code,- (liver 16, Division 3, Tillo 23, California Code cif 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 ctjtrol panel by the technician who performs the work. A copy of this form n st be provided to the tank system owner/operator. The' tner/operator iust submit a copy of this form to the local agency regt ating UST systems within 30 days of test date. • General Information Facility Name: serviced: Idg. No.: Site Address: City: Zip: Facility Contact Person: Contact Phone No.: " Make/Model of Monitoring System: Date of 'esting/Servicing: Inventory of Equipment Tested/Ce Ified Check the a in white boxes to indicate s wrifie e iii ment ills ecte. ection on Page 2) .1.%11WAI Tank Overfill / High-Level Se tor. Model: Other (s ecify e uipment type and model in Section E on age 2). Tank ID: 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. Mod Electronic Line Leak Detector. LI Tank Overfill / High-Lev Sensor. Mo Tank ID: Other (s ecify eq, it type and mode In-Tank Gauging4robe, — Mode Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). odel: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser Containment Sensor(s). Mod I: 0 Shear Valve(s). Dispenser Containment Float(s) and lain(s). e. Model: It Sensor. Model: .1: Sensor(s Model: ). Model: eak Dete or. Model: eak Det tor. Model: vel Sensor. Model: n ank Gauging Probe. r,A • Ai ilar Space or Vault Sensor. Pi sing Sump / Trench Sensor(s). 1 0 Fill SuMP,Sensor(s). Mechanical \Line Leak Detector. Electronic Lli,!e Leak Detector. Tank Overfill '/ High-Level Sensor. Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 411 Tank ID: In-Tank Gaugin Annular Spac Piping So Fill Sum chai LI E e r T n • tit mein ty e and model in Section E on Pa e T: ID: Model: Model: Model: Model: Model: Model: Model: CI Other (s fy e ui )ment ty e and model in Section Eon Pa •e 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dis )enser Containment Float(s) and Chain(s). *lithe facility contains mot - 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 the report; (check that apply): 0 System set-up 0 Alarm history report Technician Name (print): 'ZAN 1/1 41,1-10 Signature: 524, 33.2. 7 - o r Certification No.: jjg3 677-4_ tic Ozi Testing Company Name: 4 Wor Test. Phone No.:(.-QL,D? )"71 - Site Address: Date of Testing/Servicing: / LI Dispenser Containment Sensor Model: LJ Shear Valve(s). DDis enser Containment Flo (s) and Chain(s). License. No.: Monitoring System Certification Page I of 3 • 03/0 I D. Results of Testing/Servicing