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i • * ' Shields, Harper & Co . 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, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A se arate certification or report must be prqpaTed 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 must submit a copy of this form to the local agency regulating UST systems within 30 days of test date_ A. General Information Facility Name: - 4p- Bldg. No.: Site Address: City: Zip: Facility Contact Person: Contact Phone No.: ( j') Make/Model of Monitoring System: zr R S3,�_ Date of Testing/Servicing: �f B. Inventory of Equipment Tested/Certified 0 0 y70 7d -0)-- . Check the speroprinle boxes to Indicates specific equipment inspected/serviced. Tank ID: I Tank ID: Q 75 ❑ In-Tank Gauging Probe. Model: o, ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: - ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 190 -tea" ❑ Piping Sump I Trench Sensor(s). Model: 29 ❑ Fill Sump Sensor(s). P"4e Model: d - ❑ Fall Sump Sensor(s). ModeE: 2 D Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specifequipment type a PA model in Section E on Pae 2). ❑ tither 02Lcify UuiErrkent a and model in Section E on Page 2), Tank ID: Tank ID: CI In-Tank Gauging Probe. Model. 6 1/ d� Q ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 3'� %;0 ❑ Annular Space or Vault Sensor. Model: ID Piping Sump/Trench Sensor(s). Model: 29 ElPiping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s).�y Model: " '7 -2e-J ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Madel: ❑ Other(specify a ui ment t e and model in Section E on Page 22. ❑ Other(specify equipment t 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). ❑ Dis nser Containment Floats and Chain (s). ❑ Dis nser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Float(s)and Chain (s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Sensor(s). Model: D Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Floats 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 equipment. For any equipment capable of generating-such reports, hive also attached a copy of the repo • (che all that ap ly): System set-up L1r his ory re Technician Name(print): .�. a Signature: Certification No.: ' License. No.: Testing Company Name: Phone No j /6 )6 . z- Site Address: I'6 , Date ofTestin /Servicin : Page I of 4 ONO tonitoring System Certification