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R VCv Appendix VI ENVIR0NMEl4TAAL HEAICES LTH (Copies of Monitoring System Certification form and UST Monitoring Plot PWPOIZe at hftl),/Iwww.waterboa s.ca.gov.) 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 separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this forth 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: ^� v k C' <' \ t i Bldg.No.: Site Address: ! �.9-�`�.1 City: '5kW L6N _ Zip: q r G 2Z-Ajj-77�11 Facility Contact Person: n,`i� t%' Contact Phone No.: -71 MakelModel of Monitoring System: T � L �r>L7 Date of Testing/Servicing: [L I B. Inventory of Equipment Tested/Certified Check the ageroeriate boxes to indicates ecifrc equipment ins ctediserviced: Tank ID: - Tank ID: 4( In-Tank Gauging Probe. Model: O-W; -r In-Tank Gauging Probe. Model: B' Annular Space or Vault Sensor. Model: 4T Annular Space or Vault Sensor Model' ,21 Piping Sump/Trench Sensor(s). Model: - P'Piping Sump/Trench Sensorfs). Model: - ❑ Fill Sump Sensor(s). Model: ❑ 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 I High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(sped equipment t e and model in Section E on Pae 2). ❑ Other(sDecify equipment hipe and model in Section E on Pae 2). TanklD: Cil Tank ID: In-Tank Gauging Probe. Model: W&q4G-foT ❑ In-Tank Gauging Probe. Model: -e Annular Space or Vault Sensor. Model: - D_ ❑ Annular Space or Vault Sensor. Model: U�Piping Sump/Trench Sensor(s). Model: - ❑ Piping Sump I Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 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. Model: ❑ Other s eda ui ment a and model in Section E on Pa e 2. L1 Other s d e ui ment a and model in Section E on Pa 2). Dispenser lD: t .� Dispenser ID: .7 - $Dispenser Containment Sensor(s). Model: - Dispenser Contai ent Sensor(s). Model: V t-4> Shear Valve(s). Rf'Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser 10: Dispenser to: X' Dispenser Containniedt Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: K Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Djapenser ID: - Dispenser ID: b Dispenser Contain Sensor(s). Model: Va ❑ Dispenser Containment Sensor(s). Model: [�Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). "If the facility contains more tanks or dispensers,copy this forth. 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 monitorm equipment For 19y equipment capable of generating such reports,I have also attached a copy of the report:(check all that apply): t! System set-up XAlargr_history pet Technician Name(print): ')o., t` Signature: .+/s[(�/j Certification No.: License.No.: 'i�8 93 6 Testing Company Name: Phone No.:(_Jli�JEV 5 )2 Testing Company Address: b (��3� '�b�""7J''V �^ Date of Testing/Servicing: Monitoring System Certification Page t of 4 77J07 1 2/21/07